Longitudinal Coordination of Care All Hands SWG Monday, November 18, 2013

TopicPresenterTime Allotted Cognitive Status & Mental Status Templates Proposed Changes 20 minutes C-CDA Ballot ReconciliationSarah40 minutes Agenda 2

UPDATE Mental Status Section Description: The Mental Status Section contains observation and evaluations related to patient's psychological and mental competency and deficits including but not limited to any of the following types of information: Appearance (e.g., unusual grooming, clothing or body modifications) Attitude (e.g., cooperative, guarded, hostile) Behavior/psychomotor (e.g., abnormal movements, eye contact, tics) Mood and affect (e.g., anxious, angry, euphoric) Speech and Language (e.g., pressured speech, perseveration) Thought process (e.g., logic, coherence) Thought content (e.g., delusions, phobias) Perception (e.g., voices, hallucinations) Cognition (e.g., memory, alertness/consciousness, attention, orientation) – which were included in Cognitive Status Observation and Cognitive Abilities Observation in earlier publications of C-CDA. Insight and judgment (e.g., understanding of condition, decision making) While there is currently no single standard hierarchy of the aspects of mental status, the Problem Concern Act (or Health Concern Act?) may be used to group multiple Problem Observations related to Mental Status, and the Mental Status Organizer may be used to group related Mental Status Observations (e.g., results of mental tests) and associated Assessment Scale Observations. UPDATE Mental Status Observation Description: Mental Status Observation covers a broad range of mental status information, including objective and measured data to address those categories described in the Mental Status Section. See also Assessment Scale Observation for specific collections of observations that together yield a summary evaluation of a particular condition. Cognitive & Mental Status Template Change Proposals 3

ADD Mental Status Organizer (proposed NEW) Description: The Mental Status Organizer template may be used to group related Mental Status Observations (e.g., results of mental tests) and associated Assessment Scale Observations into subcategories, such as Mood and Affect, Behavior, Thought Process, Perception, Cognition, etc. UPDATE or REMOVE Cognitive Status templates (combine with Mental Status templates) REMOVE Cognitive Abilities Observation from C-CDA (or figure out how to “remove” It) RENAME Cognitive Status Observation to Mental Status Observation Ensure “cognitive” attributes/elements are included in the “mental” RENAME Cognitive Status Organizer to Mental Status Organizer Ensure “cognitive” attributes/elements are included in the “mental” REMOVE Non-medicinal Supply Activity from Mental Status Section (Functional Section) (Medical Supply, Planned) REMOVE Caregiver Characteristics from Mental Status Section (link from Social History?) REMOVE Assessment Scale Observation from Mental Status Observation and Cognitive Status Observation Table 294 – Problem Type: REPLACE Cognitive Status Finding code WITH Mental state, behavior and/or psychosocial function finding Table 359 – Mental Status Observation Type – enlarge table to include values from Cognitive and everything from Larry’s (Bill’s) Mental Status bulleted list. Also need to align with Care tool needs. What about the Mental Status Subsection and Psychiatric Subsection of Physical Exam in Appendix J in the old C-CDA? How is the Mental Status Section (NEW) related to that subsection – if at all and what is the distinction? Where is Appendix J in the new version of C-CDA? There is a reference to the appendix in the Physical Exam Section template. Cognitive & Mental Status Template Change Proposals (cont’d) 4

Sarah/Lantana will dive into the proposed changes to the Cognitive and Mental Status templates and we will use the last 20 mins of Thursday’s call to discuss any questions and counter proposals she has Next Steps 5