No Functional Impairment

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 6/18/2015, 6/15/2017
  • SDWG: 7/9/2015
  • SDWG C-CDA R2.1 Upgrade: 7/6/2017

C-CDA 2.1 Example:

  • Functional Status Section 2.16.840.1.113883.10.20.22.2.14 and 2.16.840.1.113883.10.20.22.2.14:2014-06-09
  • Functional Status Result Observation 2.16.840.1.113883.10.20.22.4.67 and 2.16.840.1.113883.10.20.22.4.67:2014-06-09

Reference to full CDA sample:

  • Functional Status in empty CCD

Validation location

Comments

  • This is an example of no functional impairment. It only illustrates one potential templated within the functional status section and was originally prepared for the ONC 2014 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. 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 no functional impairment in C-CDA R2.1.

Custodian

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

Keywords

  • no impairment

Permalink

Links

 

Example: download example view on GitHub

<section>
    <!-- This is an example of how to affirmatively assert there is no functional impairment -->
    <!-- Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section -->
    <!-- If no information is known (i.e. assessment not performed), then a pattern of null entries would be more appropriate -->
    <!-- This example uses terminology to assert 'No Impairment' rather than 'Impairment' and negationInd='true' (as value.negationInd) since template design didn't include guidance on negation. --> 
    <!-- The test data also included the No Impairment code. -->
    <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 assessment note"/>
    <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_Type1">Functional Status</td>
                    <td>August 15 2012, 5:32pm</td>
                    <td ID="FS_Finding1">No impairment</td>
                    <td/>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <observation classCode="OBS" moodCode="EVN">
            <!-- Template for Functional Status Result Observation. Note other templates may apply. -->
            <!-- We chose to use terminology to state 'no impairment' over negation since the C-CDA Functional Status template design didn't include guidance on negation-->
            <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"/>
                </originalText>
            </code>
            <text>
                <reference value="#FS_Narrative1"/>
            </text>
            <statusCode code="completed"/>
            <effectiveTime>
                <low value="20120815173215-0500"/>
            </effectiveTime>
            <value xsi:type="CD" code="66557003" codeSystem="2.16.840.1.113883.6.96"
                codeSystemName="SNOMED CT" displayName="Disability evaluation, normal, no disability, no impairment">
                <originalText>
                    <reference value="#FS_Finding1"/>
                </originalText>
            </value>
        </observation>
    </entry>
</section>
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