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pending Template  Functional Status Section

Template 2.16.840.1.113883.10.20.22.2.14 - FunctionalStatusSection
Id 2.16.840.1.113883.10.20.22.2.14
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Section Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.14
Open/Closed Open (other than defined elements are allowed)
Description The Functional Status section describes the patient’s physical state, status of functioning, and environmental status at the time the document was created. A patient’s physical state may include information regarding the patient’s physical findings as they relate to problems, including but not limited to: • Pressure Ulcers • Amputations • Heart murmur • Ostomies A patient’s functional status may include information regarding the patient relative to their general functional and cognitive ability, including: • Ambulatory ability • Mental status or competency • Activities of Daily Living (ADLs), including bathing, dressing, feeding, grooming • Home or 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 A patient’s environmental status may include information regarding the patient’s current exposures from their daily environment, including but not limited to: • Airborne hazards such as second-hand smoke, volatile organic compounds, dust, or other allergens • Radiation • Safety hazards in home, such as throw rugs, poor lighting, lack of railings/grab bars, etc. • Safety hazards at work, such as communicable diseases, excessive heat, excessive noise, etc. The patient's functional status may be expressed as a problem or as a result observation. A functional or cognitive status problem observation describes a patient’s problem, symptoms or condition. A functional or cognitive status result observation may include observations resulting from an assessment scale, evaluation or question and answer assessment. Any deviation from normal function displayed by the patient and recorded in the record should be included. Of particular interest are those limitations that would interfere with self-care or the medical therapeutic process in any way. In addition, a note of normal function, an improvement, or a change in functioning status may be included.
Used by / Uses
Used by / Uses 14 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.1.2 Containment ContinuityofCareDocumentCCD Continuity of Care Document (CCD) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.8 Containment DischargeSummary Discharge Summary 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.66 Containment FunctionalStatusResultOrganizer DYNAMIC
2.16.840.1.113883.10.20.22.4.75 Containment CognitiveStatusResultOrganizer DYNAMIC
2.16.840.1.113883.10.20.22.4.67 Containment FunctionalStatusResultObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.74 Containment CognitiveStatusResultObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.68 Containment FunctionalStatusProblemObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.73 Containment CognitiveStatusProblemObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.72 Containment CaregiverCharacteristics DYNAMIC
2.16.840.1.113883.10.20.22.4.69 Containment AssessmentScaleObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.50 Containment Non-MedicinalSupplyActivity DYNAMIC
2.16.840.1.113883.10.20.22.4.70 Containment PressureUlcerObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.76 Containment NumberofPressureUlcersObservation DYNAMIC
2.16.840.1.113883.10.20.22.4.77 Containment HighestPressureUlcerStage DYNAMIC
Item DT Card Conf Description Label
cda:section
(FunctionalStatusSection)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:7920) such that it conf‑7920
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.2.14
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:14578). conf‑14578
treeblank treetree @code
1 .. 1 F 47420-5
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree cda:title
1 .. 1 M SHALL contain exactly one [1..1] title (CONF:7922). conf‑7922
treetree cda:text
1 .. 1 M SHALL contain exactly one [1..1] text (CONF:7923). conf‑7923
treetree cda:entry
where
[cda:organizer [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.66']]
0 .. * conf‑14414
  Contains 2.16.840.1.113883.10.20.22.4.66 Functional Status Result Organizer (DYNAMIC)
treetree cda:entry
where
[cda:organizer [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.75']]
0 .. * conf‑14416
  Contains 2.16.840.1.113883.10.20.22.4.75 Cognitive Status Result Organizer (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.67']]
0 .. * conf‑14418
  Contains 2.16.840.1.113883.10.20.22.4.67 Functional Status Result Observation (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.74']]
0 .. * conf‑14420
  Contains 2.16.840.1.113883.10.20.22.4.74 Cognitive Status Result Observation (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.68']]
0 .. * conf‑14422
  Contains 2.16.840.1.113883.10.20.22.4.68 Functional Status Problem Observation (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.73']]
0 .. * conf‑14424
  Contains 2.16.840.1.113883.10.20.22.4.73 Cognitive Status Problem Observation (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.72']]
0 .. * conf‑14426
  Contains 2.16.840.1.113883.10.20.22.4.72 Caregiver Characteristics (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.69']]
0 .. * conf‑14580
  Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (DYNAMIC)
treetree cda:entry
where
[cda:supply [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.50']]
0 .. * conf‑14582
  Contains 2.16.840.1.113883.10.20.22.4.50 Non-Medicinal Supply Activity (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.70']]
0 .. * conf‑16777
  Contains 2.16.840.1.113883.10.20.22.4.70 Pressure Ulcer Observation (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.76']]
0 .. * conf‑16779
  Contains 2.16.840.1.113883.10.20.22.4.76 Number of Pressure Ulcers Observation (DYNAMIC)
treetree cda:entry
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.77']]
0 .. * conf‑16781
  Contains 2.16.840.1.113883.10.20.22.4.77 Highest Pressure Ulcer Stage (DYNAMIC)