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 List Section 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 ObservationFunctional StatusCognitive Status Frequency Observation Incontinency FrequencyBehavior Frequency Assessment 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 ObservationFunctional StatusCognitive Status Problem DysphagiaDementia Condition OrthopneaDisruptive Behavior SymptomShortness of BreathInability 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): Dressing upper body in last 7D(MDSv3) Answer (SNOMED CT): Independently able > Functional Status Result Observation (OASIS-C) Question(LOINC): Current ability: transferring Answer (SNOMED CT): independent: chair/bed transfer >Functional Status Result Observation (CARE) Question (SNOMED CT): Ability to use cutlery to feed self Answer (SNOMED CT): 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): Observational Assessment of Cognitive Status at 2D Assessment Answer (SNOMED CT): Aggressive behavior >Cognitive Status Result Observation (MDSv3) Question (LOINC): Able to recall sock Answer (LOINC): LA Yes, after cueing >Cognitive Status Result Observation (OASIS-C) Question (LOINC): Patient Health Questionnaire (PHQ-2) Answer: (SNOMED CT): 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): shortness of breath >Functional Status Problem Observation (MDSv3) Problem Type: SHALL Finding of functional performance and activity Problem (Value Set: Problems): no speech Effective time: >Functional Status Problem Observation (OASIS-C)* Problem Type: SHALL Finding of functional performance and activity Problem (Value Set: Problems): dyspnea Effective time: *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): Impaired Memory > Cognitive Status Problem Observation (MDSv3)* Problem Type: SHALL Cognitive Function Finding Problem (Value Set: Problems): Comatose Effective time: >Cognitive Status Problem Observation (OASIS-C) Problem Type: SHALL Cognitive Function Finding Problem (Value Set: Problems): Chronic confusion Effective time: *example in C-CDA IG

Caregiver Support and Ability Observation Example 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 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 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 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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