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 Updates

Assessment 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 LOINC

Answers: 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 Observation

Problem 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 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 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