Functional Status Assessments Profile

Functional Status Assessments (FSA) support the handoff of assessment information between care practictioners during transfers of care across enterprises.

Summary

In the context of the continuity of care, the Functional Status Assessment describes the patient’s status of normal functioning at the time a Continuity of Care Document (CCD) was created.

Functional status includes information concerning:

• Skin assessment
• Physical Functioning Assessment
• Assessment of Activities of Daily Living (bathing, feeding, dressing and grooming)
• Pain Management
• Mood and behavior patterns

Continuity of care requires provision of assessments to be available to the receiving practitioner for critical decision making. The transfer of physician documentation provides much of the medical/physiologic condition information. Transfer of nursing documentation provides human response (psychological, social, emotional, physiological and spiritual) of patient/family to changing conditions. Both types of documentation support continuity of patient care as each patient moves through the continuum.

This profile supports myriad patient transfers between care settings however the following three transfer events are explicitly described in this profile in order to demonstrate the variation if both data elements and workflow processes where the FSA documentation can be effectively deployed:

• Long Term Care to Acute Care, and back again
• Ambulatory Care (e.g. Assisted Living Facility) to Acute Care, and back again
• Patient Admission to a Behavioral Health Facility, and back home (with Home Healthcare follow-up)

The Functional Status Assessment Profile (FSA) support for the handoff of assessment information during transfers of care across extended stay or acute care enterprises.

The Functional Status Assessment Profile (FSA) support for the exchange of assessment information during transfers of care related to behavioral health care.

Benefits

• Ameliorates risk during the transfers of patient care between practitioners across enterprises (and intra-enterprise) which the Institute of Medicine has determined offers the highest opportunity for medical errors

Details

• This profile describes how to convey functional status information using four scales which support assessments and comparison of assessments over time. The four scales currently covered by this profile are:
  • Numeric Pain Scale
  • Braden Scale For Predicting Pressure Sore Risk
  • Geriatric Depression Scale
  • Physical Functioning and Structural Problems (Section G of the Minimum Data Set for Long Term Care)
• The functional status assessments are conveyed using medical summary documents that have been previously defined by IHE in the XDS-MS, XPHR and EDR profiles.
• Specifies the content to be extracted from an EHR system used for inpatient care delivery and how it is to be codified and organized for packing in an electronic “envelop”
• Specifies the meta-data to be used for identifying the APS document in the XDS Registry
• The creation of the FSA document is in accordance with at least one of the following options
  • Braden Scale Option
  • Geriatric Depression Score Option
  • Minimum Data Set Option
• The consumer of the FSA document must support all three of the implementation options

• Leverages HL7 Clinical Documents ontology (CDA)
  • A common mechanism for transfer of encoded clinical data embedded in documents
• Leverages the medical summary specifications used in other IHE PCC profiles

Systems Affected

• Hospital Information System modules used for care documentation
• EHR Systems in long-term care, SNIF or other extended stay care facilities
• EHR Systems in Behavioral Health facilities
• EHR Systems used by Home Healthcare agencies

Actors/Transactions

• Content Creator
• Content Consumer

There are two actors in the APS profile, the Content Creator and the Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described in the section on Content Bindings with XDS, XDM and XDR and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the FSA Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the FSA Content Consumer Actor.

See Also

Profile Status: Trial Implementation

The Patient Care Coordination Framework is the official master document for this Profile.

The Medical Summaries FAQ answers typical questions about what the Profile does.

The Medical Summaries Purchasing describes considerations when purchasing equipment to deploy this Profile.

The Medical Summaries Implementation provides additional information about implementing this Profile in software.

This page is based on the Profile Template