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.