Functional Status Assessments (FSA) Integration Profile Supplement
Introduction
This is a draft of the Functional Status Assessment Profile (FSA) supplement to the Patient Care Coordination Technical Framework. This draft is a work in progress, not the official supplement or profile.
Profile Abstract
The Functional Status Assessment Profile (FSA) has a one paragraph description.
Glossary
- Term
- Definition
Issue Log
Open Issues
- Issue
- Issue
Closed Issues
Volume I
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Dependencies
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| Integration Profile | Dependency | Dependency Type | Purpose |
|---|---|---|---|
| Functional Status Assessment |
Profile Name
The Functional Status Assessment Profile (FSA) has a one paragraph description.
And then some more introductory text.
Use Cases
Diabetic Nursing Home Patient
Primary Actor: "Discharge nurse in LTC facility, Admitting nurse in acute care facility" Stakeholder(s): "Primary Care Physician, Hospitalist" Use Case Overview: A diabetic nursing home patient is transferring from the LTC environment to an in-patient acute care hospital based on deteriorating functional status assessments.
1. A diabetic patient in a LTC facility has become increasingly weak and lethargic and has a low-grade fever. Patient refuses to get out of bed and is complaining of chills and the nurse has noted reddened area on coccyx upon braden scale assessment. Patients glucose level is elevated and the maximum sliding-scale dose indicated in medication order is not controlling the patient's blood sugar. a. Nurse charts vital signs b. Nurse charts finger-stick glucose measurement c. Nurse charts additional functional assessment d. Nurse charts braden score e. Primary care physician reviews status and makes recommendation for transfer to acute care facililty 2. The patient's baseline and standardized functional assessment is sent to the acute care hospital via the RHIO document exchange server. a. Nurse admission coordinator reviews transfer documents b. Bed is assigned on medical floor at acute care facility c. Notification of pending admission is sent to charge nurse on floor 3. Charge nurse reviews functional assessment data, VS, glucose values and braden score from LTC facility. Based on the information reviewed, nurse determines that patient may require assistance with transferring and toileting, will be at risk for falls and will require additional measures to maintain skin integrity. a. Charge nurse adjusts shift assignment based on patients level of care
4. Patient arrives in medical floor at acute care facility. a. Admitting nurse takes patient VS and completes admission assessment in EMR system b. EMR system evaluates admission assessment data and flags patient for fall risk and skin integrity problem c. Fall risk plan and skin care protocol implemented according to facility protocols
5. Patient's medical issues are addressed. a. Standard plans of care initiated in nursing documentation in EMR system
- Previous baseline functional status included in plan of care
- Expressed as patient goals prior to discharge
b. Progress and level of care requirement is continuously monitored by nurse and hospitalist assigned to patient 6. Patient regains strength and is able to transfer and toilet without assistance. a. Fall risk protocol and skin care protocol are suspended b. Nursing plan of care updated to reflect level of care patient requires" 7. After several days of care, the patient's acute medical problem is resolved and patient is functioning at previous level of self care. Patient is ready to return to LTC facility. a. Series of functional assessments and overal progress reviewed by care providers b. Plan of care is updated in EMR system c. Patient is prepared for discharge with final assessment completed
Use Case Name 2
One or more paragraphs describing a clinical scenario.
Use Case Name 3
One or more paragraphs describing a clinical scenario.
Actors/Transaction
There are two actors in this profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE profiles described below, and is out of scope of this profile. A Document Source or a Portable Media Creator may embody the Content Creator Actor. A Document Consumer, a Document Recipient or a Portable Media Importer may embody the Content Consumer Actor. The sharing or transmission of content or updates from one actor to the other is addressed by the use of appropriate IHE profiles described by section 3.7 Content Bindings with XDS, XDM and XDR found in the Patient Care Coordination Technical Framework
Options
| Actor | Option | Section |
|---|---|---|
| Content Consumer | View Option (1) Document Import Option (1) |
PCC TF-1: 2.13.1 PCC TF-1: 2.13.2 |
| Content Creator | Referral Option (1) Discharge Summary Option (1) |
PCC TF-1: 2.13.5 PCC TF-1: 2.13.6 |
Note 1: The Actor shall support at least one of these options.
Grouping
Content Bindings with XDS, XDM and XDR
It is expected that the transfers of care will occur in an environment where the physician offices and hospitals have a coordinated infrastructure that serves the information sharing needs of this community of care. Several mechanisms are supported by IHE profiles:
- A registry/repository-based infrastructure is defined by the IHE Cross Enterprise Document Sharing (XDS) and other IHE Integration Profiles such as patient identification (PIX & PDQ), and notification of availability of documents (NAV).
- A media-based infrastructure is defined by the IHE Cross Enterprise Document Media Interchange (XDM) profile.
- A reliable messaging-based infrastructure is defined by the IHE Cross Enterprise Document Reliable Interchange (XDR) profile.
- All of these infrastructures support Security and privacy through the use of the Consistent Time (CT) and Audit Trail and Node Authentication (ATNA) profiles.
For more details on these profiles, see the IHE IT Infrastructure Technical Framework.
Content profiles may impose additional requirements on the transactions used when grouped with actors from other IHE Profiles.
Cross Enterprise Document Sharing, Media Interchange and Reliable Messages
Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content Consumer sharing function of this profile. A Content Creator or Content Consumer must be grouped with appropriate actors from the XDS, XDM or XDR profiles, and the metadata sent in the document sharing or interchange messages has specific relationships to the content of the clinical document described in the content profile.
Notification of Document Availability (NAV)
A Document Source should provide the capability to issue a Send Notification Transaction per the ITI Notification of Document Availability (NAV) Integration Profile in order to notify one or more Document Consumer(s) of the availability of one or more documents for retrieval. One of the Acknowledgement Request options may be used to request from a Document Consumer that an acknowledgement should be returned when it has received and processed the notification. A Document Consumer should provide the capability to receive a Receive Notification Transaction per the NAV Integration Profile in order to be notified by Document Sources of the availability of one or more documents for retrieval. The Send Acknowledgement option may be used to issue a Send Acknowledgement to a Document Source that the notification was received and processed.
Document Digital Signature (DSG)
When a Content Creator Actor needs to digitally sign a document in a submission set, it may support the Digital Signature (DSG) Content Profile as a Document Source. When a Content Consumer Actor needs to verify a Digital Signature, it may retrieve the digital signature document and may perform the verification against the signed document content.
Content Modules
Content modules describe the content of a payload found in an IHE transaction. Content profiles are transaction neutral. They do not have dependencies upon the transaction that they appear in.
Content Module 1
Process Flow
More text about process flow
Actor Definitions
- Actor
- Definition
Transaction Definitions
- Transaction
- Definition
Volume II
Functional Status Assessment Content
Standards
- CDAR2
- Clinical Document Architecture, Release 2, 2005 HL7
- CRS
- Implementation Guide for CDA Release 2 – Level 1 and 2 – Care Record Summary (US realm), 2006, HL7.
- CCD
- ASTM/HL7 Continuity of Care Document (Draft)
- SNOMED
- Systemized Nomenclature for Medicine
Data Element Index
| Data Elements | Other Reference | LOINC Section or CDA Element |
|---|---|---|
| Numerical Pain Rating Scale | ||
| Braden Scale | ||
| MDS Section G | ||
| Geriatric Depression Scale |
Document Specification
| Data Element | Opt | Section | Template ID |
|---|---|---|---|
| Numerical Pain Rating Scale | R | 1.3.6.1.4.1.19376.1.5.3.1.3.X | |
| Braden Scale | R | 1.3.6.1.4.1.19376.1.5.3.1.3.Y | |
| MDS Section G | R | 1.3.6.1.4.1.19376.1.5.3.1.3.Z | |
| Geriatric Depression Scale | R | 1.3.6.1.4.1.19376.1.5.3.1.3.Q |
Section Template 1
| TemplateID | 1.3.6.1.4.1.19376.1.5.3.1.3.X | |
|---|---|---|
| Parent Template | 1.3.6.1.4.1.19376.1.5.3.1.3.Y | |
| General Description | This section shall ... | |
| LOINC Code | Opt | Description |
| #####-# | R | Description |
| Entries | Opt | Description |
| 1.3.6.1.4.1.19376.1.5.3.1.4.A | O | Description |
| Sub-sections | Opt | Description |
| 1.3.6.1.4.1.19376.1.5.3.1.3.D | R | Description |
Header Template 1
<entry>An XML Example</entry>
entry
Description of the entry element.
Entry Template 1
<entry>An XML Example</entry>
entry
Description of the entry element.