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Functional and Cognitive Status and Pressure Ulcer Templates Consolidation Updates. April 2012. Feedback from S&I. Provide guidance in C-CDA Implementation Guide on when to use Problems vs. Results for Functional and Cognitive status.

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Functional and cognitive status and pressure ulcer templates consolidation updates

Functional and Cognitive Status and Pressure Ulcer Templates Consolidation Updates

April 2012


Feedback from s i
Feedback from S&I

  • Provide guidance in C-CDA Implementation Guide on when to use Problems vs. Results for Functional and Cognitive status.

  • Expand ballot to include examples from other instruments such as MDS and OASIS-C.

  • Caregiver Template – expand to include both licensed and non-licensed caregiver supports

  • Assessment Scale – Create a place to describe the of meaning of the scale or how the scale was calculated

  • Pressure Ulcers – add “depth” to dimensions and include “tissue type” description for the most severe ulcers.





Functional cognitive status result observation
Functional/Cognitive Status Result Observation

  • Questions: recommend “should” be LOINC

  • Answers: recommend “should” be SNOMED-CT

  • *does not preclude using other standard vocabularies


Functional status result observation examples
Functional Status Result Observation (Examples)

  • >Functional Status Section

  • >>Functional Status Result Observation (MDSv3)*

  • Question (LOINC): 54744-8 Dressing upper body in last 7D(MDSv3)

  • Answer (SNOMED CT): 371153006 Independently able

  • > Functional Status Result Observation (OASIS-C)

  • Question(LOINC): 57246-1 Current ability: transferring

  • Answer (SNOMED CT): 165240008 independent: chair/bed transfer

  • >Functional Status Result Observation (CARE)

  • Question (SNOMED CT): 289041001 Ability to use cutlery to feed self

  • Answer (SNOMED CT): 289046006 Able to use cutlery to feed self

  • *example in C-CDA IG


Cognitive status result observation example
Cognitive Status Result Observation (Example)

  • >Functional Status Section

  • >Cognitive Status Result Observation (CARE)*

  • Question (LOINC): 5249-2 Observational Assessment of Cognitive Status at 2D Assessment

  • Answer (SNOMED CT): 61372001 Aggressive behavior

  • >Cognitive Status Result Observation (MDSv3)

  • Question (LOINC): 52735-8 Able to recall sock

  • Answer (LOINC): LA10126-3 Yes, after cueing

  • >Cognitive Status Result Observation (OASIS-C)

  • Question (LOINC): 58120-7 Patient Health Questionnaire (PHQ-2)

  • Answer: (SNOMED CT): 272022009 feeling depressed

  • *example in C-CDA IG


Functional cognitive status problem observation
Functional/Cognitive Status Problem Observation

  • Problem Types:

  • SHALL Functional Status Problem Type = Finding of functional performance and activity

  • SHALLCognitive Status Problem Type = Cognitive Function Finding


Functional status problem observation example
Functional Status Problem Observation (Example)

  • >Functional Status Section

  • >Functional Status Problem Observation (CARE)

  • Problem Type: SHALL Finding of functional performance and activity

  • Problem (Value Set: Problems): 267036007 shortness of breath

  • >Functional Status Problem Observation (MDSv3)

  • Problem Type: SHALL Finding of functional performance and activity

  • Problem (Value Set: Problems): 286375007 no speech Effective time: 04212003

  • >Functional Status Problem Observation (OASIS-C)*

  • Problem Type: SHALL Finding of functional performance and activity

  • Problem (Value Set: Problems): 162891007 dyspnea

  • Effective time: 083002011

  • *example in C-CDA IG


Cognitive status problem observation example
Cognitive Status Problem Observation (Example)

  • >Functional Status Section

  • >Cognitive Status Problem Observation (CARE)

  • Problem Type: SHALL Cognitive Function Finding

  • Problem (Value Set: Problems): 386807006 Impaired Memory

  • > Cognitive Status Problem Observation (MDSv3)*

  • Problem Type: SHALL Cognitive Function Finding

  • Problem (Value Set: Problems): 371632003 ComatoseEffective time: 04212003

  • >Cognitive Status Problem Observation (OASIS-C)

  • Problem Type: SHALL Cognitive Function Finding

  • Problem (Value Set: Problems): 130988005 Chronic confusion

  • Effective time: 083002011

  • *example in C-CDA IG


Caregiver support and ability observation example
Caregiver Support and Ability ObservationExample

  • Functional Status Section

  • >Functional Status Result Organizer: Core Self Care ( ICF or SNOMED CT)

  • Assertion example:

  • >Functional Status Result Observation

  • Question: Can the patient bring food to their mouth? (LOINC)

  • Answer: Dependent. (SNOMED CT)

  • >entry re: Caregiver Support and Ability

  • Participant Role: Home Health Nurse

  • Answer (SNOMED CT): Caregiver able

  • Non-assertion:

  • > Functional Status Result Observation

  • Question: Can the patient bring food to their mouth? (LOINC)

  • Answer: Dependent. (SNOMED CT)

  • >entry re: Caregiver Support and Ability

  • Question: ADL or IADL assistance from any caregiver *(LOINC)

  • Participant Role: Caregiver, Mother

  • Answer (SNOMED CT): Caregiver able

  • * In OASIS-C, CARE, MDSv3 instruments


Assessment scale updates
Assessment Scale updates

  • Functional Status Section

  • >Assessment Scale Observation

  • > Name of Scale (SNOMED CT): BIMS

  • >(May) Derivation Expression: Would be used to enter a calculation that was used to achieve the score in the scale or may be used to provide details on questions that may be weighted.

  • >(May)Text: The BIMS score is an aggregate sum of the results in the assessment. The total score range for BIMS is from 00 to 15 where 13 to 15 = cognitively intact, 08 to 12 = moderately impaired, 00 to 07 severely impaired.

  • >Value: 7

  • >(May) Interpretation Code

  • >(May) Author

  • >Details of Scale

  • Question: Repetition of 3 words

  • Answer: 3

  • >Details of Scale

  • Question: What year is it?

  • Answer: missed by 2-5 years


Pressure ulcer observation updates
Pressure Ulcer Observation updates

  • Plan of Care or Assessment Section

  • >Pressure Ulcer Observation

  • >Pressure Ulcer (details of a given pressure ulcer)

  • >Time of observation

  • >Pressure Ulcer Stage (Stage table)

  • >Target Site (Pressure Point table)

  • >(May) Laterality*: left or right

  • >Dimensions

  • >Length

  • >Width

  • >Depth*

  • *Green font indicates updates


Pressure ulcer observation updates1
Pressure Ulcer Observation updates

  • Plan of Care or Assessment Section

  • >Number of Pressure Ulcer by Type observation

  • >Time of observation

  • >Number of Pressure Ulcers (integer)

  • > Pressure Ulcer Stage

  • >“Highest Pressure Ulcer Stage” observation

  • >Time of observation

  • >Description of Tissue: necrotic eschar

  • *Green font indicates updates



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