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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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