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Template Functional Status Assessment Section - coded 2017‑09‑13 16:31:37

Id2.16.756.5.30.1.1.10.3.57Effective Date2017‑09‑13 16:31:37
Statusdraft DraftVersion Label2018
Namecdachsmcp_section_FunctionalStatusAssessmentCodedDisplay NameFunctional Status Assessment Section - coded
Description
The coded functional status assessment section provides 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
ContextParent nodes of template element with id 2.16.756.5.30.1.1.10.3.57
LabelCDA‑CH‑SMCP
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 1 template, Uses 2 templates
Used by as NameVersion
2.16.756.5.30.1.127.77.11.4.2Transactiondraft CDA-CH-SMCP - Social-medical care plan V2 (2018)2018‑12‑17 20:38:49
2.16.756.5.30.1.1.10.1.11Containmentdraft Social-medical care plan V2 (2018)2017‑08‑24 18:00:03
Uses as NameVersion
2.16.756.5.30.1.1.10.3.74Containmentdraft Pain Scale Assessment Section - coded (2018)DYNAMIC
2.16.756.5.30.1.1.10.3.75Containmentdraft Physical Function Section (2018)DYNAMIC
RelationshipSpecialization: template 2.16.756.5.30.1.1.10.3.23 Functional Status Assessment Section - coded (DYNAMIC)
ref
ch-pcc-

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1 IHE Coded Functional Status Assessment Section (2017‑03‑27 08:27:40)
ref
IHE-PCC-

Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.3.17 IHE Functional Status Section (DYNAMIC)
ref
IHE-PCC-
Example
Example
<section>
  <templateId root="2.16.756.5.30.1.1.10.3.57"/>  <templateId root="2.16.756.5.30.1.1.10.3.23"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.17"/>  <code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional status assessment note"/>  <title>Statut des fonctions</title>  <text>Narrative text</text>  <component>
    <!-- template 2.16.756.5.30.1.1.10.3.74 'Pain Scale Assessment Section - coded' -->
  </component>  <component>
    <!-- template 2.16.756.5.30.1.1.10.3.75 'Physical Function Section' -->
  </component></section>
ItemDTCardConfDescriptionLabel
hl7:section
CDA‑dotsSMCP
hl7:templateId
II1 … 1MCDA‑dotsSMCP
@root
uid1 … 1F2.16.756.5.30.1.1.10.3.57
hl7:templateId
II1 … 1MCDA‑dotsSMCP
@root
uid1 … 1F2.16.756.5.30.1.1.10.3.23
hl7:templateId
II1 … 1MCDA‑dotsSMCP
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
hl7:templateId
II1 … 1MCDA‑dotsSMCP
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.3.17
hl7:code
CE1 … 1MFixed, machine readable code of this section.CDA‑dotsSMCP
@code
CONF1 … 1F47420-5
@codeSystem
1 … 1F2.16.840.1.113883.6.1
@codeSystemName
1 … 1FLOINC
@displayName
1 … 1FFunctional status assessment note
hl7:title
ST1 … 1M Fixed human readable title of this section.
  • [ge]: 'Evaluation'
  • [fr]: 'Statut des fonctions'
  • [en]: 'Functional Status Assessment'
CDA‑dotsSMCP
 Variable letNamelanguageCode 
 Valuesubstring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2) 
 Schematron assertrolered error 
 testnot($languageCode='ge') or (text()='Evaluation') 
 MessageThe German title must read 'Evaluation' 
 Schematron assertrolered error 
 testnot($languageCode='fr') or (text()='Statut des fonctions') 
 MessageThe French title must read 'Statut des fonctions' 
 Schematron assertrolered error 
 testnot($languageCode='en') or (text()='Functional Status Assessment') 
 MessageThe English title must read 'Functional Status Assessment' 
hl7:text
SD.TEXT1 … 1RHuman readable text of this section.CDA‑dotsSMCP
hl7:component
1 … *MContains 2.16.756.5.30.1.1.10.3.74 Pain Scale Assessment Section - coded (DYNAMIC)CDA‑dotsSMCP
hl7:component
0 … *Contains 2.16.756.5.30.1.1.10.3.75 Physical Function Section (DYNAMIC)CDA‑dotsSMCP
 Schematron assertrolered error 
 test//hl7:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3'] or //hl7:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4'] or //hl7:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5'] 
 MessageAt least one of the optional subsections shall be present {1.3.6.1.4.1.19376.1.5.3.1.1.12.2.3, 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.4, 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5}