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.
• 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
Functional Status Result Organizer
Functional Status Result Observation
Functional Status Problem
Observation
Additional items
Caregiver Support and
Ability Observation
Assessment Scale
Observations
Cognitive status
Cognitive Status Result Organizer
Cognitive Status Result Observation
Cognitive Status Problem
Observation
Pressure Ulcer UpdatesAssessment
Section
Pressure Ulcer Observation
Number of Pressure Ulcers
Highest Stage of Pressure
Ulcers
Problem ListSection
Pressure Ulcer
Plan of Care Section
Pressure Ulcer Observation
Number of Pressure Ulcers
Highest Stage of Pressure
Ulcers
Add Results vs. Problem tables to C-CDA IG
Result Observation Functional Status Cognitive StatusFrequency Observation Incontinency Frequency Behavior FrequencyAssessment Scale or Evaluation Result
Pain Scale Brief Interview for Mental Status
Assessment Question/Answer
Eating Independent Partial/Moderate
Assistance Substantial Assistance Dependent
Disorganized thinking Behavior not present Behavior continuously
present Behavior present,
fluctuates
Problem Observation Functional Status Cognitive Status
Problem Dysphagia Dementia
Condition Orthopnea Disruptive Behavior
Symptom Shortness of Breath Inability to Recall
Functional/Cognitive Status Result Observation
Questions: recommend “should” be LOINCAnswers: recommend “should” be SNOMED-CT
*does not preclude using other standard vocabularies
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: transferringAnswer (SNOMED CT): 165240008 independent:
chair/bed transfer
>Functional Status Result Observation (CARE) Question (SNOMED CT): 289041001 Ability to use cutlery
to feed selfAnswer (SNOMED CT): 289046006 Able to use cutlery to
feed self
*example in C-CDA IG
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 sockAnswer (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 ObservationProblem Types:• SHALL Functional Status Problem Type = Finding of
functional performance and activity• SHALL Cognitive Status Problem Type = Cognitive
Function Finding
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)>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 ObservationExampleFunctional 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 updatesFunctional 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 wordsAnswer: 3
>Details of ScaleQuestion: What year is it?Answer: missed by 2-5 years
Pressure Ulcer Observation updatesPlan 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 updatesPlan 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
Discussion