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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. 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

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  1. Functional and Cognitive Status and Pressure Ulcer Templates Consolidation Updates April 2012

  2. 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.

  3. Functional Status Section Updates

  4. Pressure Ulcer Updates

  5. Add Results vs. Problem tables to C-CDA IG

  6. Functional/Cognitive Status Result Observation • Questions: recommend “should” be LOINC • Answers: recommend “should” be SNOMED-CT • *does not preclude using other standard vocabularies

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. Discussion

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