1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1

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The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif Coded Functional Status Assessment Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Parent Template Functional Status (1.3.6.1.4.1.19376.1.5.3.1.3.17)
General Description The coded functional status assessment section provided a machine readable and narrative description of the patient’s status of normal functioning at the time the document was created.

Functional status includes information concerning:

  • Ambulatory ability
  • Mental status or competency
  • Activities of Daily Living (ADL’s) including bathing, dressing, feeding, grooming
  • Home/living situation having an effect on the health status of the patient
  • Ability to care for self
  • Social activity, including issues with social cognition, participation with friends and acquaintances other than family members
  • Occupation activity, including activities partly or directly related to working, housework or volunteering, family and home responsibilities or activities related to home and family
  • Communication ability, including issues with speech, writing or cognition required for communication
  • Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance
LOINC Code Opt Description
47420-5 R Functional Status Assessment
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2 R Pain Scale Assessment
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3 O Braden Score Assessment
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4 O Geriatric Depression Scale
1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 O Minimum Data Set


At least one of the above optional subsections shall be present

Standards
CDAR2 HL7 CDA Release 2.0
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
LOINC Logical Observation Identifier Names and Codes
SNOMED Systemitized Nomenclature of Medicine Clinical Terminology
Parent Template

The parent of this template is Functional Status.

Sample Coded Functional Status Assessment Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/> <id root=' ' extension=' '/> <code code='47420-5' displayName='Functional Status Assessment' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'/> <!-- Required Pain Scale Assessment Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3'/> <!-- Optional Braden Score Assessment Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4'/> <!-- Optional Geriatric Depression Scale Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5'/> <!-- Optional Minimum Data Set Section content --> </section> </component>
    </section> </component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Coded Functional Status Assessment can only be used on sections. 
   </assert> 
   <!-- Verify that the parent templateId is also present. --> 
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     Error: The parent template identifier for Coded Functional Status Assessment is not present. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "47420-5"]'> 
     Error: The section type code of a Coded Functional Status Assessment must be 47420-5 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Coded Functional Status Assessment Section must contain a(n) Pain Scale Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Braden Score Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Geriatric Depression Scale Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5"]'> 
     <!-- Note any missing optional elements -->
     Note: This Coded Functional Status Assessment Section does not contain a(n) Minimum Data Set Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
   <assert test="./cda:component/cda:section/cda:templateId[
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3' or
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4' or
                   @root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5']">
     At least one of the optional subsections must be in a coded functional assessment.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Coded Functional Status Assessment Section