Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Functional Status Section

[Section: templateId 2.16.840.1.113883.10.20.22.2.14]

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.

  1. SHALL contain exactly one [1..1] templateId ( CONF:10389 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.14"
  2. SHALL contain exactly one [1..1] code/@code="47420-5" Functional status assessment (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF:7921)
  3. SHALL contain exactly one [1..1] title (CONF:7922)
  4. SHALL contain exactly one [1..1] text (CONF:7923)
  5. MAY contain zero or more [0..*] entry (CONF:14414, CONF:14415)
    1. Contains exactly one [1..1] Functional Status Result Organizer (templateId: 2.16.840.1.113883.10.20.22.4.66)
  6. MAY contain zero or more [0..*] entry (CONF:14416, CONF:14417)
    1. Contains exactly one [1..1] Cognitive Status Result Organizer (templateId: 2.16.840.1.113883.10.20.22.4.75)
  7. MAY contain zero or more [0..*] entry (CONF:14418, CONF:14419)
    1. Contains exactly one [1..1] Functional Status Result Observation (templateId: 2.16.840.1.113883.10.20.22.4.67)
  8. MAY contain zero or more [0..*] entry (CONF:14420, CONF:14421)
    1. Contains exactly one [1..1] Cognitive Status Result Observation (templateId: 2.16.840.1.113883.10.20.22.4.74)
  9. MAY contain zero or more [0..*] entry (CONF:14422, CONF:14423)
    1. Contains exactly one [1..1] Functional Status Problem Observation (templateId: 2.16.840.1.113883.10.20.22.4.68)
  10. MAY contain zero or more [0..*] entry (CONF:14424, CONF:14425)
    1. Contains exactly one [1..1] Cognitive Status Problem Observation (templateId: 2.16.840.1.113883.10.20.22.4.73)
  11. MAY contain zero or more [0..*] entry (CONF:14426, CONF:14427)
    1. Contains exactly one [1..1] Caregiver Characteristics (templateId: 2.16.840.1.113883.10.20.22.4.72)
  12. MAY contain zero or more [0..*] entry (CONF:14580, CONF:14581)
    1. Contains exactly one [1..1] Assessment Scale Observation (templateId: 2.16.840.1.113883.10.20.22.4.69)
  13. MAY contain zero or more [0..*] entry (CONF:14582, CONF:14583)
    1. Contains exactly one [1..1] Non Medicinal Supply Activity (templateId: 2.16.840.1.113883.10.20.22.4.50)
  14. MAY contain zero or more [0..*] entry (CONF:16777, CONF:16778)
    1. Contains exactly one [1..1] Pressure Ulcer Observation (templateId: 2.16.840.1.113883.10.20.22.4.70)
  15. MAY contain zero or more [0..*] entry (CONF:16779, CONF:16780)
    1. Contains exactly one [1..1] Number Of Pressure Ulcers Observation (templateId: 2.16.840.1.113883.10.20.22.4.76)
  16. MAY contain zero or more [0..*] entry (CONF:16781, CONF:16782)
    1. Contains exactly one [1..1] Highest Pressure Ulcer Stage (templateId: 2.16.840.1.113883.10.20.22.4.77)