3.4 Functional Status

The template identifier for the functional status section is 2.16.840.1.113883.10.20.1.5.

Functional Status describes the patient’s status of normal functioning at the time the Care Record was created. Functional statuses include information regarding the patient relative to:

• Ambulatory ability
• Mental status or competency
• Activities of Daily Living (ADLs), 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

Any deviation from normal function that the patient displays and is recorded in the record should be included. Of particular interest are those limitations that would in any way interfere with self care or the medical therapeutic process. In addition, an improvement, any change in or noting that the patient has normal functioning status is also valid for inclusion.

CONF-123: CCDSHOULD contain exactly one and SHALL NOT contain more than one Functional status section (templateId 2.16.840.1.113883.10.20.1.5). The Functional status section SHALL contain a narrative block, and SHOULD contain clinical statements. Clinical statements SHOULD include one or more problem acts (templateId 2.16.840.1.113883.10.20.1.27) and/or result organizers (templateId 2.16.840.1.113883.10.20.1.32).

3.4.1 Section conformance

CONF-124: The functional status section SHALL contain Section / code.
CONF-125: The value for “Section / code” SHALL be “47420-5” “Functional status assessment” 2.16.840.1.113883.6.1 LOINC STATIC.
CONF-126: The functional status section SHALL contain Section / title.
CONF-127: Section / titleSHOULD be valued with a case-insensitive language-insensitive text string containing “functional status”.

3.4.2 Clinical statement conformance

The template identifier for a problem act is 2.16.840.1.113883.10.20.1.27.
The template identifier for a problem observation is 2.16.840.1.113883.10.20.1.28.
The template identifier for a result organizer is 2.16.840.1.113883.10.20.1.32.
The template identifier for a result observation is 2.16.840.1.113883.10.20.1.31.

Functional Statuses can be expressed in 3 different forms. They can occur as a Problem (see section 3.5 Problems), a Result (see section 3.13 Results) or as text. Text can be employed if and only if the Functional Status is neither a Problem nor a Result. Functional Statuses expressed as Problems include relevant clinical conditions, diagnoses, symptoms and findings. Results are the interpretation or conclusion derived from a clinical assessment or test battery, such as the Instrumental Activities of Daily Living (IADL) scale or the Functional Status Index (FSI).

CONF-128: A problem observation or result observation in the functional status section SHALL contain exactly one observation / code.
CONF-129: The value for “Observation / code” in a problem observation or result observation in the functional status section MAY be selected from ValueSet 2.16.840.1.113883.1.11.20.6 FunctionalStatusTypeCode STATIC 20061017.
CONF-130: If the functional status was collected using a standardized assessment instrument, then the instrument itself SHOULD be represented in the “Organizer / code” of a result organizer, with a value selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96) .
CONF-131: If the functional status was collected using a standardized assessment instrument, then the question within that instrument SHOULD be represented in the “Observation / code” of a result observation, with a value selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96).
CONF-132: If the functional status was collected using a standardized assessment instrument containing questions with enumerated values as answers, then the answer SHOULD be represented in the “Observation / value” of a result observation.
CONF-133: If Observation / value in a result observation in the functional status section is of data type CE or CD, then it SHOULD use the same code system used to code the question in Observation / code.
CONF-134: Observation / value in a result observation in the functional status section MAY be of datatype CE or CD and MAY contain one or more Observation / value / translation, to represent equivalent values from other code systems.
CONF-135: A problem observation or result observation in the functional status section MAY use codes from the International Classification of Functioning, Disability, and Health (ICF, http://www.who.int/classifications/icf/en/) (codeSystem 2.16.840.1.113883.6.254).

3.4.2.1 Representation of “status” values

The template identifier for a status of functional status observation is 2.16.840.1.113883.10.20.1.44.

CONF-136: A problem observation in the functional status section SHALL contain exactly one status of functional status observation.
CONF-137: A result observation in the functional status section SHALL contain exactly one status of functional status observation.
CONF-138: A status of functional status observation (templateId 2.16.840.1.113883.10.20.1.44) SHALL be a conformant status observation (templateId 2.16.840.1.113883.10.20.1.57) (as defined in section 5.1 “Type” and “Status” values).
CONF-139: The value for “Observation / value” in a status of functional status observation SHALL be selected from ValueSet 2.16.840.1.113883.1.11.20.5 StatusOfFunctionalStatusCode STATIC 20061017.