Functional and Cognitive Status and Pressure Ulcer Templates Consolidation Updates - PowerPoint PPT Presentation

Functional and cognitive status and pressure ulcer templates consolidation updates
Download
1 / 16

  • 63 Views
  • Uploaded on
  • Presentation posted in: General

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.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

Functional and Cognitive Status and Pressure Ulcer Templates Consolidation Updates

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


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 status section updates

Functional Status Section Updates


Pressure ulcer updates

Pressure Ulcer Updates


Add results vs problem tables to c cda ig

Add Results vs. Problem tables to C-CDA IG


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


Functional and cognitive status and pressure ulcer templates consolidation updates

Discussion


  • Login