{{|Title Page| Domain=Patient Care Coordination| Volume=Cross-Enterprise Sharing of Medical Summaries (XDS-MS) Integration Profile| Revision=2.0| Year=2006-2007| Status=Draft}}

Functional Status Assessment (FSA) Integration Profile

Scope and Purpose

Profile Abstract

The Functional Status Assessment Profile (FSA) supports the handoff of assessment information between practictioners during transfers of care by defining the Functional Status Assessment option on the XDS-MS and XPHR profiles.

The Institute of Medicine has determined that the highest risk for medical errors occurs during the handoffs of patient care between practitioners, cross-enterprise or intra-enterprise. 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 demonstrates the collection and exchange of standardized assessment information as it is exchanged across a variety of residential and care provision settings.

Glossary

Term: Definition

IHE Functional Status Assessments Profile Glossary of Terms

IHE Integration Profiles describe the solution to a specific integration problem, and document the system roles, standards and design details for implementors to develop systems that cooperate to address that problem. IHE Profiles are a convenient way for implementors and users to be sure they're talking about the same solution without having to restate the many technical details that ensure actual interoperability.

Continuity of Care Record (CCR): A core data set of the most relevant administrative, demographic, and clinical information facts about a patient’s healthcare, covering one or more encounters. The CCR is Designation E2369-05 of the ASTM (American Society for Testing and Materials, International). More information is available from [1].

Continuity of Care Document(CCD): An HL7 Clinical Document Architecture (CDA) implementation alternative to ASTM ADJE2369 for institutions or organizations committed to HL7 standards. This specification was developed as a collaborative effort between ASTM and HL7. More information is available from [2].

Clinical Document Architecture (CDA): A document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange. From the perspective of CDA the CCR is a standardized data set that can be used to constrain CDS specifically for summary documents. More information is available from [3].

Logical Observation Identifiers Names and Codes( LOINC®) A database protocol developed by the Regenstrief Institute for Health Care aimed at standardizing laboratory and clinical code for use in clinical care, outcomes management, and research. LOINC® codes (sometimes in combination with SNOMED-CT codes are used to encode functional status assessments to facilitated health information exchange. Additional information found at [4].

Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT®): A comprehensive clinical terminology, originally created by the College of American Pathologists (CAP) and, as of April 2007, owned, maintained, and distributed by the International Health Terminology Standards Development Organisation (IHTSDO), a non-for-profit association in Denmark. The CAP continues to support SNOMED CT operations under contract to the IHTSDO and provides SNOMED-related products and services as a licensee of the terminology. More information available from [5] or the United States National Library of Medicine at [6]

Volume I

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{{{1}}} - {{{3}}}

Dependencies

Add the following row(s) to the list of dependencies

Integration Profile	Dependency	Dependency Type	Purpose
Functional Status Assessment	XDS-MS

Functional Status Assessment

The Functional Status Assessment Profile (FSA) supports the handoff of assessment information between practictioners during transfers of care.

In the context of the Continuity of Care Document, the functional status describes 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

The Institute of Medicine has determined that the highest risk for medical errors occurs during the handoffs of patient care between practitioners, cross-enterprise or intra-enterprise. 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 does not convey the entire functional status, but is an initial interoperabe entry to manage continuity of care with the use of four scales which support assessment comparison related to time/date,informing caregivers for critical decision making. The profile demonstrates the collection and exchange of standardized assessment information as it is exchanged across a variety of residential and care provision settings.

Options

This integration profile supplement adds the following two options to the Cross Enterprise Sharing of Medical Summaries (XDS-MS) Integration Profile, and to the Exchange of Personal Health Record Content (XPHR) Integration Profile.

Functional Status Assessment Options
Actor	Option
Content Consumer	Functional Status Option
Content Creator	Functional Status Option

Functional Status Option

A Content Consumer Actor implementing the Functional Status Option of this profile supplement shall be able to view and consume coded functional status information sent in the functional status section of a Medical Summary or XPHR Extract. If the Content Consumer implements any of the import options of those profiles, it shall be able to import the coded functional status information.

A Content Creator Actor implementing the Functional Status Option of this profile supplement shall be able to create a coded functional status section that contains at least one of the optional functional status assessments in a Medical Summary or XPHR Extract.

This option has the effect of adding the Functional Assessments data element as a required data element in the XPHR Extract, Referral or Discharge Summary content modules.

For Public Comment

How should we handle this profile? Should the coded functional status section be added to XDS-MS and XPHR as conditionally required (when the Functional Status Option is declared on the actor), or should this profile be published on its own.

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.

Coded Functional Status Assessment

The coded functional status assessment section contains one or more subsections that included coded functional status assessment information. This is a section content profile that is intended to be used in Medical Summaries of various type, including those described in the XDS Medical Summaries profile, and the XPHR profile. The subsections that are defined by this content profile are further described below.

Numeric Pain Scale

Using the Numeric Pain Scale (NRS 11), a Patient rates his/her pain from 0 to 10, with 0 representing no pain and 10 representing the worst possible pain. This scale is used for age 5 years and older and is the preferred pain scale for many older healthy adults. Reliable and valid per Herr & Garland, 2001; Ho et al, 1996; Price et al, 1994.

This content profile describes how a Pain Scale assessment is reported in a CDA Document.

Braden Scale For Predicting Pressure Sore Risk

The Braden Scale For Predicting Pressure Sore Risk is a summated rating scale made up of six subscales scored from 1-3 or 4, for total scores that range from 6-23. The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levers of risk for pressure ulcer development. Reliability and validity research found at [7] Media:braden.pdf

This content profile illustrates how to record the Braden Score within a CDA document.

Geriatric Depression Scale

While there are many instruments available to measure depression, the Geriatric Depression Scale (GDS), first created by Yesavage et al.,(Stanford University) has been tested and used extensively with the older population. It is a brief questionnaire in which participants are asked to respond to the 30 questions by answering yes or no in reference to how they felt on the day of administration. Scores of 0 - 9 are considered normal, 10 - 19 indicate mild depression and 20 - 30 indicate severe depression. The GDS may be used with healthy, medically ill and mild to moderately cognitively impaired older adults. It has been extensively used in community, acute and long-term care settings. As for evidence-based research the GDS was found to have 92% sensitivity and 89% specificity when evaluated against diagnostic criteria per the Hartford Institute for Geriatric Nursing. The validity and reliability of the tool have been supported through both clinical practice and research. More information is available from [8].

This content profile illustrates how to record the Geriatric Depression Scale within a CDA document.

Minimum Data Set

The Minimum Data Set for Long Term Care Version 2.0 (MDS 2.0) is a federally mandated (in the United States) standard assessment form. This instrument is specified by the Centers for Medicare and Medicaid Services, and requires nursing facilities to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity. Section G Physical Functioning and Structural Problems are included in this demonstration project. More information is found at[9]. Media:SectionG_MDS20.pdf

Process Flow

Three use cases are described in futher detail below.

Long-Term Care to Acute Care - describes a use case for assessment information during transfers of care from long term to acute care.
[[#Home/Assisted Living into Acute Care, transfer to Rehab and then Home/Ambulatory care] - describes a use case for assessment information during multiple care transfers.
Behavioral - describes a use case for assessment information during transfers of care where information about depression in an older patient is used.

Note:

Italicized text in the use cases below denote information in the use case that provides details regarding patient condition and workflow, but will not be included as part of the content integration profile.

Long-Term Care to Acute Care

Media:Visio-UseCase1-Diagram-v2.pdf

Primary Actor(s): 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.

Use Case Scenario

A 76 year old resident/patient of a LTC facility has become increasingly weak, lethargic and has a low-grade fever. Resident refuses to get out of bed and is complaining of chills and the nurse noted reddened area on coccyx during assessment. Resident's glucose level is elevated and the maximum sliding-scale dose indicated in medication order is not controlling blood sugar.
1. Nurse documents vital signs.
2. Nurse documents finger-stick glucose measurement.
3. Nurse documents current functional assessment.
4. Nurse documents braden score.
5. Nurse initiates phone collaboration with Primary Care Provider (PCP).
6. Primary care provider (PCP) reviews patient status information on the electronic health record (EHR).
7. PCP enters transfer order to acute care facililty via computerized physician order entry (CPOE).
The patient's baseline and standardized functional assessment is sent to the acute care hospital via a document exchange server.
1. Nurse admission coordinator reviews transfer documents via the EHR. Note: Having the comprehensive patient information available allows the admission coordinator more time to shift patients and prepare for the patient.
2. Bed is assigned on medical floor at acute care facility.
3. Notification of pending admission is sent to charge nurse on the medical floor.
Charge nurse reviews the patient's functional status assessment data, VS, glucose values and braden score from LTC facility. Note: The charge nurse is provided additional time to reassign other patients and/or allowing the admitting nurse more time to prepare for the patient admission.
1. Based on the information reviewed, Charge nurse adjusts shift assignment based on patients level of care.
Patient arrives in medical floor at acute care facility.
1. Admitting nurse takes patient VS and completes admission assessment in EHR. Note: Nurse completes assessment at the point of care promoting more time at the bedside.
2. EHR evaluates admission assessment data and identifies patient skin integrity problem due to Braden Score and fall risk.
3. Electronic health record flags need for skin care protocol to clinician. Note: Electronic notifications are an adjunct to support the critical thinking skills of the nurse taking care of the patient and reinforce the proactive monitoring and management of patient's safety needs.
4. Skin care protocol and fall risk protocol implemented according to facility protocols.
5. Acute care physician assesses patient and reviews nurse assessment data in EHR.
Patient's medical issues are addressed during course of hospitalization (5 days).
1. Standard plans of care (POC) initiated in nursing documentation in EHR.
  - Previous baseline functional status included in patient's POC. Note: Nurse is able to review data on-line and quickly update based on availability of baseline data. No need to waste time and call the LTC facility or get a fax of information since it is readily available.
  - Expressed as patient goals prior to discharge.
2. Progress and level of care requirement is continuously monitored by nurse and hospitalist assigned to patient
After several days of care, patient ready for discharge as evidenced by blood sugar levels WNL and increased functional status (including ambulation with assistance).
1. Series of functional assessments and overal progress reviewed by care providers. ## Nursing POC updated in EHR to reflect level of care (functional status) and unresolved skin risk.
2. Acute care physician enters discharge order via CPOE.
3. PCP notified of transfer back to LTC facility and review of patient status.
Long Term Care/Hospital collaborate on discharge plan/transfer. Note: Multiple series of assessment data that can be quickly reviewed and compared promotes multi-disciplinary decision making.
1. Patient readied for discharge, EHR documents completed.
2. EHR discharge documents sent to document exchange server; message sent to LTC to download documents.
3. Patient returns to LTC.

Home/Ambulatory Care into Acute Care

Media:Visio-UseCase-2_Diagram.pdf

Primary Actor(s): ED Nurse, ED Doctor, Surgeon, Orthopedic nurse in acute care facility, Nurse in rehab facility, Clinical staff in assisted living facility
Secondary Actor(s): Paramedics, Physical Therapist
Stakeholder(s): Primary Care Physician, Hospitalist
Use Case Overview: A normally active, older adult in an assisted living community has an accidental fall requiring admission to an acute care facility. Alteration in functional status requires the patient discharge to a nursing home for rehabilitation with the long term goal of returning to assisted living.

Use Case Scenario

A 69 year old single male, living in an assisted community, is normally very active and self sufficient and requires only minimal assistance from staff for medication management. While walking outside, the patient falls and breaks his hip. The patient has a large 10 cm hematoma on his side with bruising that extends down his right hip and leg. He has a laceration on his forehead from his glasses breaking durign the fall. The patient is pale, and complaining of severe pain in his right hip. The patient is unable to move and an ambulance is called. Patient is transferred from the assisted living community to the emergency department at an acute care facility. There is no baseline functional assessment data available from the assisted living community.
1. Nurse charts vital signs
2. Nurse documents information regarding hematoma and area of brusing on right side
3. Nurse documents information regarding head laceration and covers wound with 2x2 gauze/tape.
4. Primary care physician is notified of ambulance transfer to acute care facililty
The patient's history from the assisted living community is reviewed with the paramedics before the patient is moved to the ambulance prior to transfer to the acute care facility emergency department.
1. Paramedics are provided with a brief summary of patient including age, date of birth, medical history, medications and allergies.
Patient is brought to emergency department of acute care facility and is assessed by clinical staff. Nurse and physician assigned to patient review accident information and patient history via the electronic health record. The nurse performs a thorough assessment of the patient's current conditionl x-rays and labs are ordered. Patient is medicated for pain prior to the x-ray. ED doctor determines patient has hip fracture and recommends patient be transferred to the orthopedic floor with a surgical consult.
1. ED nurse charts vital signs and accident information in electronic health record.
2. ED nurse assesses patient's level of pain using numeric rating scale in the electronic health record.
3. ED nurse notifies doctor of pain score.
4. ED doctor assesses patient and reviews history.
5. ED doctor orders hip x-ray and pain medication in electronic health record
6. ED doctor writes up admission to ortho floor and orders surgical consult in the electronic health record.
Patient transferred to orthopedic floor at acute care facility and has surgical consult.
1. Admitting nurse takes patient VS and completes admission assessment including numeric pain rating scale in the electronic health record.
2. The electronic health record evaluates admission assessment data entered by the clinician and flags patient for skin integrity problem and fall risk.
3. Skin care and fall risk protocol implemented in the electronic health record according to facility protocols.
4. Surgeon assesses patient condition and recommends total hip replacement surgery.
Patient has surgery and returns to orthopedic floor. Nurses continue to monitor patient, dress wounds and assess pain level and medicate as needed. Patient begins physical therapy 1st day post-op.
1. Standard plans of care initiated in nursing documentation in electronic health record.
  - Previous baseline functional status included in plan of care post total hip replacement.
  - Expressed as patient goals prior to discharge.
2. Patient's pain level is assessed pre and post medication using numeric rating scale and documented in electronic health record.
3. Progress and level of care requirement is continuously monitored by nurse and surgeon assigned to patient.
4. Physical therapist establishes rehabilitation plan and goals post total hip surgery and documents progress in electronic health record.
Patient regains strength and is able to transfer and toilet with assistance. Staples have been removed from hip incision and bruising is resolving. Patients level of pain has dropped significantly since admission and is requiring less pain medication.
1. Skin care protocol is suspended.
2. Nursing plan of care updated to reflect level of care patient requires.
After several days of care post total hip surgery, the patient is progressing, but still not able to function independently (at previous baseline). The surgeon recommends the patient be transferred to a rehabilitation facility for more intense therapy.
1. Series of functional assessments and overal progress reviewed by care providers.
2. Plan of care is updated in the electronic health record.
3. Primary care physician is notified of plan to transfer.
4. Patient is prepared for discharge to rehabilitation facility with final assessment completed.
The patient's baseline and standardized functional assessment is sent to the rehabilitation facility via a document exchange server.
1. Rehabilitation facility nurse admission coordinator reviews transfer documents.
2. Bed is assigned on orthopedic floor at rehabilitation facility.
3. Notification of pending admission is sent to charge nurse on the floor at the rehabilitation facility.
Charge nurse reviews patient accident history, functional assessment data, and patient progress from acute care facility. Based on the information reviewed, nurse determines that patient will require assistance transferring, toileting and ambulation and will be at risk for falls.
1. Rehab facility charge nurse adjusts shift assignment based on patients level of care.
Patient regains strength and is able to transfer, toilet and ambulate with minimal assistance after one week and has not required pain medicine the last 3 days. Surgeon recommends patient for transfer back to assisted living facility.
1. Series of functional assessments and overal progress reviewed by care providers.
2. Plan of care is updated in EMR system.
3. Primary care physician is notified of plan to transfer patient back to assisted living facility.
4. Patient is prepared for discharge to assisted living facility with final assessment completed.
The patient's baseline and standardized functional assessment is sent to the assisted living facility via a document exchange server.
1. Series of functional assessments and overal progress from rehabilitation center is reviewed by assisted living care providers.
Assisted living clinical staff review patients hospitalization and rehab history, functional assessment data, and patient progress. Based on the information reviewed, nurse determines that patient will require assistance transferring, toileting and ambulation and will be at risk for falls.
1. Series of functional assessments and overal progress reviewed by care providers.
2. Patient's assisted living needs have been updated to reflect fall risk and assistance with ambulation, toileting and transfer in the electronic health record.

Behavioral

Media:Visio-UseCase-3_Diagram.pdf

Primary Actor(s): Psychiatric nurse, Attending physician/hospitalist, Home health nurse
Stakeholder(s): Primary Care Physician, Outpatient psychiatrist
Use Case Overview: A recently widowed 75 year old woman is admitted to an adult inpatient floor of a behavior health hospital for depression post suicide attempt

Use Case Overview

A 75 year old woman who lives alone and has become increasingly withdrawn since the sudden death of her husband 6 weeks ago took several days worth of medication at one time from her pill pack. A neighbor found her in her home confused and immediately took her to her psychiatrists office. Patient was diagnosed as depressed by her psychiatrist, and was a direct admission from her doctor's office to an adult inpatient floor in a behavioral health facility.
Psychiatrist notes patient issue regarding depression into electonic health record notes.
Patient screened by adult inpatient admission nurse using the geriatric depression scale. Her initial score was 26, indicating severe depression. Patient information was entered into the electronic health record. Patient states that she has a hard time getting going each day and is afraid of how she will survive without her husband. She has lost her appetite and is unhappy with her life without her husband.
1. Nurse documents geriatric depression scale results in the electronic health record.
2. Nurse documents patient's feelings and concerns in progress notes in the electronic health record.
3. Nurse initiates plan of care for management of depression.
Psychiatrist reviews the patient's progress and visits patient. Psychiatrist orders anti-depressant and mood stabilizer medications via CPOE.
Social work evaluates the patient for her social support and financial status. The patient has no limitations in activity of daily living. She has a housekeeper come in monthly to clean and does her own grocery shopping and laundry weekly. Her nearest relative is over 1,000 miles away and her only support network are friends and neighbors that are also frail and elderly. The social worker also collaborates with the nurse regarding the signs of depression and the geriatric depression scale score. The plan of care is initiated and discharge planning begins.
Daily, nursing gives patient medication and assesses the patient's depression status using the geriatric depression scale. Various support therapy sessions provided to patient to improve mood and outlook for the future.
1. Nurse documents administration of medication.
2. Nurse documents depression assessment.
3. Nurse documents patient's response to therapies.
4. Nurse documents udpate to the plan of care.
After 5 days, patient is progressing well and responding to therapy. Most recent geriatric depression scale score documented in the electronic health record is 15, indicating mild depression.
1. Nurse documents administration of medication.
2. Nurse documents depression assessment.
3. Nurse documents patient's response to therapies.
4. Nurse documents udpate to the plan of care.
Patient care conference is done with patient, nurse, social worker and physician. Based on progress, patient will be discharged to home with home health visits.
1. Patient's plan of care is updated.
2. Physician enters discharge to home order with home health services into the electronic health record.
Patient is discharged home with home health referral.
Home health nurse reviews patient status electronically and prepares for visit to patient home.
1. Home health nurse reviews geriatric depression scale ratings from hospital and history of patient stay and underlying issues.
Home health nurse visits patient at home.
1. Nurse assesses patient using the geriatric depression scale and enters into the electronic health record.
2. Nurse assesses patient using oasis and enters into the electronic health record.
Outpatient psychiatrist reviews patient's progress from home health and follows up with patient.
1. Psychiatrist reviews geriatric depression scale rating since returning home in electronic health record.
2. Psychiatrist reviews home health Oasis assessment information in electronic health record.

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)

LOINC: Logical Observation Identifiers Names and Codes

SNOMED: Systemized Nomenclature for Medicine

CDA Section Content Modules

Development Only

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Coded Functional Status Assessment Section

LOINC Code	Opt	Description
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
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

Development Only

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Pain Scale Assessment Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2
General Description	The Pain Scale Assessment contains a coded observation reflecting the patient's reported intensity of pain on a scale from 0 to 10.
38208-5	R	Pain severity
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1	R	Pain Score Observation

Sample Pain Scale Assessment Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'/>
    <id root=' ' extension=' '/>
    <code code='38208-5' displayName='Pain severity'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Pain Score Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Pain Scale Assessment can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "38208-5"]'> 
     Error: The section type code of a Pain Scale Assessment must be 38208-5 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Pain Scale Assessment Section must contain a(n) Pain Score Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Pain Scale Assessment Section

Development Only

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Braden Score Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3
General Description	This section reports the braden score and its related assessments in machine and human readable form.
38228-3	R	BRADEN SCALE SKIN ASSESSMENT PANEL
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2	R	Braden Score Observation

Sample Braden Score Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3'/>
    <id root=' ' extension=' '/>
    <code code='38228-3' displayName='BRADEN SCALE SKIN ASSESSMENT PANEL'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Braden Score Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Braden Score can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "38228-3"]'> 
     Error: The section type code of a Braden Score must be 38228-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Braden Score Section must contain a(n) Braden Score Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Braden Score Section

Development Only

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Geriatric Depression Scale Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4
General Description	This section reports the Geriatric Depression Scale score and its related assessments in machine and human readable form.
48542-5	R	Geriatric Depression Scale (GDS) Panel
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4	R	Geriatric Depression Score Observation

Sample Geriatric Depression Scale Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4'/>
    <id root=' ' extension=' '/>
    <code code='48542-5' displayName='Geriatric Depression Scale (GDS) Panel'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Geriatric Depression Score Observation element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Geriatric Depression Scale can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "48542-5"]'> 
     Error: The section type code of a Geriatric Depression Scale must be 48542-5 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Geriatric Depression Scale Section must contain a(n) Geriatric Depression Score Observation Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Geriatric Depression Scale Section

Development Only

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Physical Function Section

LOINC Code	Opt	Description
Template ID	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5
General Description	This section reports scores from section G of the Minimum Data Set.
46006-3	R	Physical functioning and structural problems
Entries	Opt	Description
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7	O	Survey Panel At least one Survey Panel or Survey Observation shall be present.
1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6	O	Survey Observations At least one Survey Panel or Survey Observation shall be present.

Sample Physical Function Section

<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5'/>
    <id root=' ' extension=' '/>
    <code code='46006-3' displayName='Physical functioning and structural problems'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Optional Survey Panel element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7'/>
         :
    </entry> 
    <entry>
         :
      <!-- Optional Survey Observations element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6'/>
         :
    </entry>
       
  </section>
</component>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Physical Function can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "46006-3"]'> 
     Error: The section type code of a Physical Function must be 46006-3 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Function Section does not contain a(n) Survey Panel Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6"]'> 
     <!-- Note any missing optional elements -->
     Note: This Physical Function Section does not contain a(n) Survey Observations Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6"] or 
                 .//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7"]'>
     At least one Survey Panel or Survey Observation shall be present.
     See http://www.ihe.net/index.php/1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5
   </assert> 
 </rule> 
</pattern>

Uses

See Templates using the Physical Function Section

Constraints

Survey Panels found in this section shall be identified using the panel codes found in the table below, and shall contain one or more survey observations from that panel.

Survey Observations found in this section shall use the LOINC codes from the table below to express the answer to one or more questions from the Minimum Data Set Section G. The Survey Observations shall not contain a <methodCode> or <targetSiteCode> element, as these are not appropriate to the MDS Survey instrument.

Panel Code	Observation Code	Description	Data Type	Value Set
46007-1	Panel	ADL self performance or support
	45588-1	Bed mobility - self-performance	CO	2.16.840.1.113883.6.257.755
	45589-9	Bed mobility - support provided	CO	2.16.840.1.113883.6.257.768
	45590-7	Transfer - self-performance	CO	2.16.840.1.113883.6.257.755
	45591-5	Transfer - support provided	CO	2.16.840.1.113883.6.257.768
	45592-3	Walk in room - self-performance	CO	2.16.840.1.113883.6.257.755
	45593-1	Walk in room - support provided	CO	2.16.840.1.113883.6.257.768
	45594-9	Walk in corridor - self-performance	CO	2.16.840.1.113883.6.257.755
	45595-6	Walk in corridor - support provided	CO	2.16.840.1.113883.6.257.768
	45596-4	Locomotion on unit - self-performance	CO	2.16.840.1.113883.6.257.755
	45597-2	Locomotion on unit - support provided	CO	2.16.840.1.113883.6.257.768
	45598-0	Locomotion off unit - self-performance	CO	2.16.840.1.113883.6.257.755
	45599-8	Locomotion off unit - support provided	CO	2.16.840.1.113883.6.257.768
	45600-4	Dressing - self-performance	CO	2.16.840.1.113883.6.257.755
	45601-2	Dressing - support provided	CO	2.16.840.1.113883.6.257.768
	45602-0	Eating - self-performance	CO	2.16.840.1.113883.6.257.755
	45603-8	Eating - support provided	CO	2.16.840.1.113883.6.257.768
	45604-6	Toilet use - self-performance	CO	2.16.840.1.113883.6.257.755
	45605-3	Toilet use - support provided	CO	2.16.840.1.113883.6.257.768
	45606-1	Personal hygiene - self-performance	CO	2.16.840.1.113883.6.257.755
	45607-9	Personal hygiene - support provided	CO	2.16.840.1.113883.6.257.768
46008-9	Panel	Bathing
	45608-7	Bathing - self-performance	CO	2.16.840.1.113883.6.257.860
	45609-5	Bathing - support provided	CO	2.16.840.1.113883.6.257.768
46009-7	Panel	Test for balance
	45610-3	Balance while standing	CO	2.16.840.1.113883.6.257.876
	45523-8	Balance while sitting	CO	2.16.840.1.113883.6.257.876
46010-5	Panel	Functional limitation in range of motion
	45524-6	Range of motion^Neck	CO	2.16.840.1.113883.6.257.889
	45525-3	Voluntary movement^Neck	CO	2.16.840.1.113883.6.257.898
	45526-1	Range of motion^Upper Extremity	CO	2.16.840.1.113883.6.257.889
	45527-9	Voluntary movement^Upper Extremity	CO	2.16.840.1.113883.6.257.898
	45528-7	Range of motion^Hand	CO	2.16.840.1.113883.6.257.889
	45529-5	Voluntary movement^Hand	CO	2.16.840.1.113883.6.257.898
	45530-3	Range of motion^Lower Extremity	CO	2.16.840.1.113883.6.257.889
	45531-1	Voluntary movement^Lower Extremity	CO	2.16.840.1.113883.6.257.898
	45532-9	Range of motion^Foot	CO	2.16.840.1.113883.6.257.889
	45533-7	Voluntary movement^Foot	CO	2.16.840.1.113883.6.257.898
	45534-5	Other - range of motion	CO	2.16.840.1.113883.6.257.889
	45535-2	Other - voluntary movement	CO	2.16.840.1.113883.6.257.898
46011-3	Panel	Modes of locomotion
	45536-0	Uses cane, walker or crutch	CO	2.16.840.1.113883.6.257.117
	45537-8	Wheeled self	CO	2.16.840.1.113883.6.257.117
	45538-6	Other person wheeled	CO	2.16.840.1.113883.6.257.117
	45539-4	Uses wheelchair for primary locomotion	CO	2.16.840.1.113883.6.257.117
	45540-2	No modes of locomotion	CO	2.16.840.1.113883.6.257.117
46012-1	Panel	Modes of transfer
	45541-0	Bedfast all or most of the time	CO	2.16.840.1.113883.6.257.117
	45542-8	Bed rails for bed mobility or transfer	CO	2.16.840.1.113883.6.257.117
	45543-6	Lifted manually	CO	2.16.840.1.113883.6.257.117
	45544-4	Lifted mechanically	CO	2.16.840.1.113883.6.257.117
	45545-1	Transfer aid	CO	2.16.840.1.113883.6.257.117
	45546-9	No mode of transfer	CO	2.16.840.1.113883.6.257.117
No Panel	45611-1	Task segmentation	CO	2.16.840.1.113883.6.257.117
46013-9	Panel	ADL functional rehabilitation potential
	45612-9	Resident sees increased independence capability	CO	2.16.840.1.113883.6.257.117
	45613-7	Staff sees increased independence capability	CO	2.16.840.1.113883.6.257.117
	45614-5	Resident slow performing tasks or activity	CO	2.16.840.1.113883.6.257.117
	45615-2	Difference in morning to evening activities of daily living	CO	2.16.840.1.113883.6.257.117
	45616-0	Activities of daily living rehabilitation potential - none of above	CO	2.16.840.1.113883.6.257.117
	45617-8	Change in activities of daily living function	CO	2.16.840.1.113883.6.257.464

The coded orginal values used in the observations above are described in more detail in the table below.

Explanation	Coded Value
2.16.840.1.113883.6.257.755
INDEPENDENT-No help or oversight -OR- Help/oversight provided only 1 or 2 times during last 7 days	0
SUPERVISION-Oversight, encouragement or cueing provided 3 or more times during last7 days -OR- Supervision (3 or more times) plus physical assistance provided only 1 or 2 times during last 7 days	1
LIMITED ASSISTANCE-Resident highly involved in activity; received physical help in guided maneuvering of limbs or other nonweight bearing assistance 3 or more times - OR-More help provided only 1 or 2 times during last 7 days	2
EXTENSIVE ASSISTANCE-While resident performed part of activity, over last 7-day period, help of following type(s) provided 3 or more times: - Weight-bearing support - Full staff performance during part (but not all) of last 7 days	3
TOTAL DEPENDENCE-Full staff performance of activity during entire 7 days	4
ACTIVITY DID NOT OCCUR during entire 7 days	8
2.16.840.1.113883.6.257.768
No setup or physical help from staff	0
Setup help only	1
One person physical assist	2
ADL activity itself did not occur during entire 7 days	8
2.16.840.1.113883.6.257.860
Independent-No help provided	0
Supervision-Oversight help only	1
Physical help limited to transfer only	2
Physical help in part of bathing activity	3
Total dependence	4
Activity itself did not occur during entire 7 days	8
2.16.840.1.113883.6.257.876
Maintained position as required in test	0
Unsteady, but able to rebalance self without physical support	1
Partial physical support during test; or stands (sits) but does not follow directions for test	2
Not able to attempt test without physical help	3
2.16.840.1.113883.6.257.889
No limitation	0
Limitation on one side	1
Limitation on both sides	2
2.16.840.1.113883.6.257.898
No loss	0
Partial loss	1
Full loss	2
2.16.840.1.113883.6.257.117
No	0
Yes	1
UTD	-
2.16.840.1.113883.6.257.464
No change	0
Improved	1
Deteriorated	2

CDA Entry Content Modules

Development Only

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

Pain Score Observation 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1

The pain score observation is a Simple Observation that records the patient's assessment of their pain on a scale from 0 to 10.

Parent Template

The parent of this template is Simple Observation.

Uses

See Templates using Pain Score Observation

Specification

Pain Score Observation Example

<observation typeCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root=1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <id root=' ' extension=' '/>
 <code code='38208‑5|38221‑8|38214‑3' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
   <translation code='406127006' displayName='Pain intensity'
     codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='CO|REAL' />
 <interpretationCode code= codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>

The <templateId> identifies this as a Pain Score Observation, and shall be present as shown above.

<code code='38208‑5' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
<translation code='406127006' displayName='Pain intensity' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <code> element indicates what kind of pain observation was made. It shall contain the code and codeSystem attribute values shown above. The <translation> element may be present, and provides a mapping to SNOMED CT of the observation. If present, is shall have the code and codeSystem attribute values shown above.

Pain Score Codes
Code	Data Type	Description
38208‑5	CO	A Pain Score made using the Numerical Rating Scale (NRS), where pain is assessed on a scale from 0 to 10. -->>The code system to use for this observation<<--

<value xsi:type='CO' value=' ' />

The <value> element records the assessed pain score. If using the NRS the pain is assessed using coded ordinal values that range from 0 to 10. The use of the coded ordinal type is required because while pain assessments are ordered values, and can be compared, the differences between two pain assessment values cannot be compared, and so these values are not really numbers.

<interpretationCode code='301379001|40196000|76948002|67849003' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <interpretationCode> element should be present to provide an interpretation of the pain scale assessment using SNOMED CT. When the <interpretationCode> element is present, the <translation> element described above shall be present. These interpretations are provided to assist decision support systems that are making secondary use of the assessment information, and are not intended to replace the score values.

Pain Score Interpretation Codes
Pain Score Range	Code	Description
0	301379001	No Present Pain
1-3	40196000	Mild Pain
4-6	50415004	Moderate Pain
7-9	76948002	Severe Pain
10	67849003	Excruciating Pain

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <methodCode> should not be present in a Pain Score Observation, as the method is implied by the <code> element.

<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <targetSiteCode> element should be present, and shall indicate the location of the pain being assessed.

Development Only

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

Braden Score Observation 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2

The Braden Scale is a summated rating scale made up of six subscales scored from 1-3 or 4, for total scores that range from 6-23. The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levers of risk for pressure ulcer development. This entry shows how to record the Braden Score and its component assessment scores.

Uses

See Templates using Braden Score Observation

Specification

Braden Score Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2'/>
 <id root=' ' extension=' '/>
 <code code='38227‑5' 
       displayName='Braden scale score.total' 
       codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
   <translation code='225392000' displayName='Pressure sore risk assessment'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='SNOMED CT'/>
 
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='INT' value=' '/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <!-- Six entries, containing each of the assessment components -->
 <entryRelationship typeCoded='COMP'>
   <observation classCode='OBS' moodCode='EVN'>
     <tempateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3'/>
        :
   </observation>
 </entryRelationship>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2'/>

These <templateId> elements identify this entry as a Braden Score Observation. Furthermore, they identify it as a CCD Result entry, and a Simple Observation. They shall be present as shown above.

<code code='38227‑5' displayName='Braden scale score.total' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
<translation code='225392000' displayName='Pressure sore risk assessment'
codeSystem=2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <code> element identifies this observation as being a Braden Scale Score. The <translation> element shall be sent to indicate that this score is an assessment of pressure sore risk.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and records the Braden Score for the patient. The value shall be within the range of 6 to 23 inclusive.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode> may be present to indicate the risk for pressure sores. It shall contain a code from the table below using SNOMED CT.

Braden Score Interpretation Codes
Braden Score	Interpretation	SNOMED CT Code	SNOMED CT Description
19-23	No risk of pressure sores	260413007	None
15-18	Risk of pressure sores	30207005	Risk Of
13-14	Moderate risk of pressure sores	25594002	Moderate risk of
10-12	High risk of pressure sores	15508007	High risk of
6-9	Very high risk of pressure sores	Not Available¹	Very high risk of

¹	Code value pending results of submission to SNOMED

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

<entryRelationship typeCoded='COMP'>
<observation classCode='OBS' moodCode='EVN'>
<tempateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3'/>

The Braden score is made up of six assessments. Each assessment is scored individually. The overall score indicates the patient risk for pressure sores, and the individual component scores help the reciever of the information determine the appropriate interventions. Thus, a Braden Score Observation shall always be transmitted with all of its component assessments. See Braden Score Component for details on encoding the assessment components.

Development Only

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

Braden Score Component 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3

This entry supports the recording of the observations from the six subscales of the Braden Score. These scales are scored from 1-3 or 4. The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. This entry shows how to record the assessment scores Braden Score components.

Uses

See Templates using Braden Score Component

Specification

Braden Score Component Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3'/>
 <id root=' ' extension=' '/>
 <code code='38222‑6|38229‑1|38223‑4|38224‑2|38225‑9|38226‑7' 
       displayName=' ' 
       codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
   <translation code=' ' displayName=' ' 
     codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='INT' value=' '/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3'/>

These <templateId> elements identify this entry as a Braden Score Component. Furthermore, they identify it as a CCD Result entry, and a Simple Observation. They shall be present as shown above.

<code code='38222‑6|38229‑1|38223‑4|38224‑2|38225‑9|38226‑7'
displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
<translation code=' ' displayName=' '
codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <code> element identifies which component of the Braden Scale is being assessed in this observation. The valid LOINC codes are listed in the second column of the table below.

Braden Component Score Codes
Component	LOINC Code	SNOMED CT Code	SNOMED CT Description
Sensory Perception	38222-6	248240001	response to pain
Moisture Exposure	38229-1	364532007	moistness of skin
Physical Mobility	38224-2	249864002	ability to assume and maintain a position
Physical Activity	38223-4	68130003	physical activity
Nutrition Intake Pattern	38225-9	87276001	nutritional status
Friction and Shear	38226-7	301438001	ability to mobilize

The translation element should be sent to provide a translation of the measure to the SNOMED CT coding system. The code attribute of the translation element shall contain the matching SNOMED CT code from column three in the table above. The displayName attribute may be present, and should contain text similar to the matching description from column four of the table above.

<effectiveTime value=' '/>

The <effectiveTime> element need not be present, as it is already recorded in the observation for which this is a component.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and records the Braden Score for the component assessed. The value shall be within the range of 1 to 4 inclusive for all components except the Friction/Shear score, which shall be within the range of 1 to 3 inclusive.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode> may be present to interpret the score value using SNOMED CT. Interpretations for each of the scores for each assessment component are shown in the table below. When the <interpretionCode> element is present, the <translation> element described above shall be present. These interpretations are provided to assist decision support systems that are making secondary use of the assessment information, and are not intended to replace the score values.

Braden Component Score Interpretation Codes
Component	LOINC Code	Score	SNOMED CT Interpretation Code	SNOMED CT Description
Sensory Perception	38222-6	1	42341009	Agnosia
		2	425403003	Limited sensory perception
		3	425403003	Limited sensory perception
		4	247700009	Normal perception
Moisture Exposure	38229-1	1	255238004	Continuous
		2	70232002	Frequent
		3	84638005	Occasional
		4	89292003	Rare
Physical Mobility	38224-2	1	302045007	Does not mobilize
		2	160692006	Mobility very poor
		3	8510008	Reduced mobility
		4	302042005	Able to mobilize
Physical Activity	38223-4	1	160685001	Bed-ridden
		2	160684002	Confined to chair
		3	84638005	Occasional
		4	70232002	Frequent
Nutrition Intake Pattern	38225-9	1	255351007	Poor
		2	71978007	Inadequate
		3	88323005	Adequate
		4	425405005	Excellent
Friction and Shear	38226-7	1	301684000	Does not move in bed
		2	301697003	Difficulty moving up and down bed
		3	301693004	able to move up and down bed

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <methodCode> and <targetSiteCode> elements shall not be used.

Development Only

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

Geriatric Depression Score Observation 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4

The Geriatric Depression Scale is a summated rating scale over 30 yes or no questions for total scores that range from 0-30. This entry shows how to record the Geriatric Depression Score and its component assessment scores.

Uses

See Templates using Geriatric Depression Score Observation

Specification

Geriatric Depression Score Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4'/>
 <id root=' ' extension=' '/>
 <code code='48544-1' 
       displayName='Geriatric Depression Scale Total' 
       codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='INT' value=' '/>
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <!-- From 0 to 30 entries, containing some or all of the assessment components -->
 <entryRelationship typeCoded='COMP'>
   <observation classCode='OBS' moodCode='EVN'>
     <tempateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5'/>
        :
   </observation>
 </entryRelationship>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.4'/>

These <templateId> elements identify this entry as a Geriatric Depression Score Observation. Furthermore, they identify it as a CCD Result entry, and a Simple Observation. They shall be present as shown above.

<code code='48544-1' displayName='Geriatric Depression Scale Total' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

The <code> element identifies this observation as being a Geriatric Depression Score.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and records the Geriatric Depression Score for the patient. The value shall be within the range of 0 to 30 inclusive.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <interpretationCode> should be present to indicate the interpretation of the assessment score. It shall contain a code from the table below using SNOMED CT. When SNOMED CT codes are sent in the <interpretationCode> element, the <translation> element described above shall be present. These interpretations are provided to assist decision support systems that are making secondary use of the assessment information, and are not intended to replace the score values.

Geriatric Depression Score Interpretation Codes
Geriatric Depression Score	SNOMED CT Code	Description
0-9	134417007	Level of mood – normal
10-19	310496002	Moderate depression
20-30	310497006	Severe depression

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <methodCode> and <targetSiteCode> elements shall not be used in a Geriatric Depression Score Observation.

<entryRelationship typeCoded='COMP'>
<observation classCode='OBS' moodCode='EVN'>
<tempateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5'/>

The Geriatric Depression Score is made up of 30 assessments. Each assessment is scored individually. The overall score indicates the patient risk for depression. The individual components may help the reciever of the information determine appropriate interventions, but need not be present to make the score usefull. Thus, a Braden Score Observation may transmit some or all of its component assessments. See Geriatric Depression Score Component for details on encoding the assessment components.

Development Only

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

Geriatric Depression Score Component 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5

This entry supports the recording of the observations from the 30 sumcomponents of the Geriatric Depression Score. These scales are scored using a value of 0 or 1. This entry shows how to record the assessment scores Geriatric Depression Score components.

Uses

See Templates using Geriatric Depression Score Component

Specification

Geriatric Depression Score Component Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5'/>
 <id root=' ' extension=' '/>
 <code code=' ' displayName=' ' 
       codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='INT' value=' '/>
 <interpretationCode code='373066001|373067005' displayName='Yes|No'
      codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.5'/>

These <templateId> elements identify this entry as a Geriatric Depression Score Component. Furthermore, they identify it as a CCD Result entry, and a Simple Observation. They shall be present as shown above.

<code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

The <code> element identifies which component of the Geriatric Depression Scale is being assessed in this observation. The valid codes are listed in the table below.

Geriatric Depression Component Codes and Scores
LOINC Code	Question	Yes Score	No Score
48512-8	Are you basically satisfied with your life	0	1
48513-6	Have you dropped many of your activities and interests	1	0
48514-4	Do you feel that your life is empty	1	0
48515-1	Do you often get bored	1	0
48516-9	Are you hopeful about the future	0	1
48517-7	Are you bothered by thoughts you cannot get out of your head	1	0
48518-5	Are you in good spirits most of the time	0	1
48519-3	Are you afraid that something bad is going to happen to you	1	0
48520-1	Do you feel happy most of the time	0	1
48521-9	Do you often feel helpless	1	0
48522-7	Do you often get restless and fidgety	1	0
48523-5	Do you prefer to stay at home, rather than going out and doing new things	1	0
48524-3	Do you frequently worry about the future	1	0
48525-0	Do you feel you have more problems with memory than most	1	0
48526-8	Do you think it is wonderful to be alive now	0	1
48527-6	Do you often feel downhearted and blue	1	0
48528-4	Do you feel pretty worthless the way you are now	1	0
48529-2	Do you worry a lot about the past	1	0
48530-0	Do you find life very exciting	0	1
48531-8	Is it hard for you to get started on new projects	1	0
48532-6	Do you feel full of energy	0	1
48533-4	Do you feel that your situation is hopeless	1	0
48534-2	Do you think that most people are better off than you are	1	0
48535-9	Do you frequently get upset over little things	1	0
48536-7	Do you frequently feel like crying	1	0
48537-5	Do you have trouble concentrating	1	0
48538-3	Do you enjoy getting up in the morning	0	1
48539-1	Do you prefer to avoid social gatherings	1	0
48540-9	Is it easy for you to make decisions	0	1
48541-7	Is your mind as clear as it used to be	1	0

<effectiveTime value=' '/>

The <effectiveTime> element need not be present, as it is already recorded in the observation for which this is a component.

<value xsi:type='INT' value=' '/>

The <value> element shall be present, and records the Geriatric Depression Score for the component assessed. The value shall contain either 0 or 1.

<interpretationCode code='373066001|373067005' displayName='Yes|No' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

The <interpretationCode> may be present to describe the meaning of the score value. Interpretations for each of the scores for each assessment component are shown in the table below.

Geriatric Depression Score Component Interpretation Codes
SNOMED CT Code	Description
373066001	Yes
373067005	No

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <methodCode> and <targetSiteCode> elements shall not be used.

Development Only

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

Survey Observation 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6

Survey observations are used to record responses to assessment instruments. They are simple observations conforming to the CCD Result template. The vocabulary and data type constraints on survey observations is specified elsewhere, either in the specializations of the survey observation template, or by the template that makes use of it.

Parent Template

The parent of this template is Simple Observation. This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.31

Uses

See Templates using Survey Observation

Specification

Survey Observation Example

<observation classCode='OBS' moodCode='EVN'>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
 <templateId root='2.16.840.1.113883.10.20.1.31'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6'/>
 <id root=' ' extension=' '/>
 <code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
 <text><reference value='#xxx'/></text>
 <statusCode code='completed'/>
 <effectiveTime value=' '/>
 <repeatNumber value=' '/>
 <value xsi:type='CO|CD|INT|PQ' />
 <interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
 <targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>
</observation>

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
<templateId root='2.16.840.1.113883.10.20.1.31'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6'/>

A survey observation shall have the <templateId> elements shown above to indicate that it inherits constraints from the ASTM/HL7 CCD Specification for results, and the constraints of this specification.

<code code=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>

A survey observation entry shall contain a code identifying the observation made.

<value xsi:type='CO|CD|INT|PQ' .../>

The <value> element shall be present, and shall be of the appropriate data type specified for the observation.

<interpretationCode code=' ' codeSystem=' ' codeSystemName=' '/>

An interpretation code may be present to provide an interpretation of the observation.

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>
<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

The <methodCode> and <targetSiteCode> element shall not be present, as these are not relevant to survey responses.

Development Only

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

Survey Panel 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7

A survey panel collects related survey observations.

Parent Template

This template is compatible with the ASTM/HL7 Continuity of Care Document template: 2.16.840.1.113883.10.20.1.32

Uses

See Templates using Survey Panel

Specification

Survey Panel Example

<organizer classCode='CLUSTER' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.32'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7'/>
  <id root='' extension=''/>
  <code code=' ' displayName=' ' 
    codeSystem=' ' codeSystemName=' '/>
  <statusCode code='completed'/>
  <effectiveTime value=''/>
  <!-- one or more survey observations -->
  <component typeCode='COMP'>
    <observation classCode='OBS' moodCode='EVN'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.6'/>
        :
    </observation>
  </component>
</organizer>

<organizer classCode='CLUSTER' moodCode='EVN'>

The survey panel is a cluster of related survey observations.

<templateId root='2.16.840.1.113883.10.20.1.32'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.7'/>

The survey panel shall have the <templateId> elements shown above to indicate that it inherits constraints from the ASTM/HL7 CCD Specification for results organizers, and the constraints of this specification.

<id root=' ' extension=' '/>

The organizer shall have an <id> element.

<code code=' ' displayName=' '
codeSystem=' '
codeSystemName=' '/>

The <code> element shall be present, and identifies the survey panel.

<statusCode code='completed'/>

The observations have all been completed.

<effectiveTime value=' '/>

The effective time element shall be present to indicate when the survey panel was taken.

<component typeCode='COMP'>

The organizer shall have one or more <component> elements that are <observation> elements using the Survey Observation template.

LOINC Codes for Selected Instruments

Media:LOINCified MDS Section G.pdf

Semantic Mapping of Contents of LOINC-ified Instruments to SNOMED Concepts

Media:LOINCified MDS to SNOMED Mappings.xls

This mapping was funded by DHHS/ASPE (The Office of the Assistant to the Secretary for Planning and Evaluation within the Department of Health and Human Services)

The plan is for these mappings to be loaded to the UMLS' Metathesaurus. Although these mappings have been validated by MDS experts, they have not been validated by SNOMED experts. The expectation is that these mappings will continue to be validated and updated by appropriate stakeholders.

Media:SNOMED_Braden_ScoreMappingV201JUN07.pdf

Media:Geriatric_Depression_ScaleV201JUN07.pdf

Media:SNOMED_PAIN_NRS_Mapping01JUN07.pdf

Functional Status Assessments (FSA) Integration Profile Supplement

Functional Status Assessment (FSA) Integration Profile

Scope and Purpose

Profile Abstract

Glossary

Volume I

Dependencies

Functional Status Assessment

Options

Functional Status Option

Content Modules

Coded Functional Status Assessment

Numeric Pain Scale

Braden Scale For Predicting Pressure Sore Risk

Geriatric Depression Scale

Minimum Data Set

Process Flow

Long-Term Care to Acute Care

Home/Ambulatory Care into Acute Care

Behavioral

Volume II

Functional Status Assessment Content

Standards

CDA Section Content Modules

Development Only

Coded Functional Status Assessment Section

Standards

Parent Template

Schematron

Uses

Development Only

Pain Scale Assessment Section

Schematron

Uses

Development Only

Braden Score Section

Schematron

Uses

Development Only

Geriatric Depression Scale Section

Schematron

Uses

Development Only

Physical Function Section

Schematron

Uses

Constraints

CDA Entry Content Modules

Development Only

Pain Score Observation 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1

Parent Template

Uses

Specification

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>

<code code='38208‑5' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> <translation code='406127006' displayName='Pain intensity' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

<value xsi:type='CO' value=' ' />

<interpretationCode code='301379001|40196000|76948002|67849003' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

<methodCode code=' ' codeSystem=' ' codeSystemName=' '/>

<targetSiteCode code=' ' codeSystem=' ' codeSystemName=' '/>

Development Only

Braden Score Observation 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2

Uses

Specification

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/><templateId root='2.16.840.1.113883.10.20.1.31'/><templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.3.2'/>

<code code='38227‑5' displayName='Braden scale score.total' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'> <translation code='225392000' displayName='Pressure sore risk assessment' codeSystem=2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

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Development Only

Braden Score Component 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.3

Uses

Specification

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Development Only

<code code='38208‑5' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'>
<translation code='406127006' displayName='Pain intensity' codeSystem='2.16.840.1.113883.6.96' codeSystemName='SNOMED CT'/>

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<translation code='225392000' displayName='Pressure sore risk assessment'
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<templateId root='2.16.840.1.113883.10.20.1.32'/>
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<component typeCode='COMP'>