Functional Impairment

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Example metadata last updated 2017-08-26 11:42:42.145000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 6/15/2017
  • SDWG: 7/6/2017

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Certification

Comments:

  • This is an example of a functional impairment. It only illustrates one potential templated within the functional status section and was originally prepared for the ONC 2014 Transitions of Care test scenario, inpatient for MU2 170.314(b)(2). Note that there are significant changes to functional and cognitive status in C-CDA 2.1 (including section breakout and deprecation of certain templates). This example represents the proper way to send a functional impairment in C-CDA R2.1.

Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard) and John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Full sample: Functional Status in empty CCD

Example: download example view on GitHub

<section>
    <!-- This is an example of how to affirmatively assert there is a functional impairment -->
    <!-- Original design influenced by Transitions of Care test scenario, inpatient for MU2 170.314(b)(2)-->
    <!-- Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section -->
    <templateId root="2.16.840.1.113883.10.20.22.2.14"/>
    <templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
    <code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional Status"/>
    <title>Functional Status</title>
    <!-- Narrative organized as a single table. Some systems may prefer simple paragraph-->
    <text>
        <table>
            <thead>
                <tr>
                    <th>Assessment</th>
                    <th>Date</th>
                    <th>Results</th>
                    <th>Comments</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="FS_Narrative1">
                    <td ID="FS_Type">Functional Status</td> 
                    <td>August 15 2012, 5:32pm</td>
                    <td ID="FS_Finding1">Dependence on walking stick</td>
                    <td></td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <observation classCode="OBS" moodCode="EVN">
            <!-- Template for Functional Status Observation. Note other templates may apply. -->
            <templateId root="2.16.840.1.113883.10.20.22.4.67"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.67" extension="2014-06-09"/>
            <id root="e4f9eb37-52ca-4e95-90f3-570dace107e6"/>
            <code code="54522-8" displayName="Functional status" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC">
                <originalText>
                    <reference value="#FS_Type1"></reference>
                </originalText>
            </code>
            <text>
                <reference value="#FS_Narrative1"/>
            </text>
            <statusCode code="completed"/>
            <effectiveTime>
                <!-- Some systems may just report this to day rather than hour and minute timestamp. Both of which are acceptable. -->
                <low value="20120815173215-0500"/>
            </effectiveTime>
            <value xsi:type="CD" code="105504002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Dependence on walking stick">
                <originalText>
                    <reference value="#FS_Finding1"/>
                </originalText>
            </value>
        </observation>
    </entry>
</section>
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