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draft Template  Functional Status Assessment Section - coded

Id 2.16.756.5.30.1.1.10.3.57 Effective Date 2017‑09‑13 16:31:37
Status draft Draft Version Label 2018
Name cdachsmcp_section_FunctionalStatusAssessmentCoded Display Name Functional 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
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.3.57
Label CDA‑CH‑SMCP
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 1 template, Uses 2 templates
Used by as Name Version
2.16.756.5.30.1.1.10.1.11 Containment draft Social-medical care plan V2 (2018) 2017‑08‑24 18:00:03
Uses as Name Version
2.16.756.5.30.1.1.10.3.74 Containment draft Pain Scale Assessment Section - coded (2018) DYNAMIC
2.16.756.5.30.1.1.10.3.75 Containment draft Physical Function Section (2018) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.3.23 (DYNAMIC)
Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1 (2017‑03‑27 08:27:40)
Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.3.17 (DYNAMIC)
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>
Item DT Card Conf Description Label
hl7:section
 CDA-dotsSMCP
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.3.57
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.3.23
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
hl7:templateId
 II 1 … 1 M CDA-dotsSMCP
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.17
hl7:code
 CE 1 … 1 M Fixed, machine readable code of this section. CDA-dotsSMCP
@code
 CONF 1 … 1 F 47420-5
@codeSystem
 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@codeSystemName
 1 … 1 F LOINC
@displayName
 1 … 1 F Functional status assessment note
hl7:title
 ST 1 … 1 M Fixed human readable title of this section.
  • [ge]: 'Evaluation'
  • [fr]: 'Statut des fonctions'
  • [en]: 'Functional Status Assessment'
 CDA-dotsSMCP
  Variable let Name languageCode  
  Value substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='ge') or (text()='Evaluation')  
  Message The German title must read 'Evaluation'  
  Schematron assert role red error  
  test not($languageCode='fr') or (text()='Statut des fonctions')  
  Message The French title must read 'Statut des fonctions'  
  Schematron assert role red error  
  test not($languageCode='en') or (text()='Functional Status Assessment')  
  Message The English title must read 'Functional Status Assessment'  
hl7:text
 SD.TEXT 1 … 1 R Human readable text of this section. CDA-dotsSMCP
hl7:component
 1 … * M Contains 2.16.756.5.30.1.1.10.3.74 Pain Scale Assessment Section - coded (DYNAMIC) CDA-dotsSMCP
treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.74'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.39'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.2']]]
hl7:component
 0 … * Contains 2.16.756.5.30.1.1.10.3.75 Physical Function Section (DYNAMIC) CDA-dotsSMCP
treeblank where [hl7:section [hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.75'] and hl7:templateId [@root = '2.16.756.5.30.1.1.10.3.40'] and hl7:templateId [@root = '1.3.6.1.4.1.19376.1.5.3.1.1.12.2.5']]]
  Schematron assert role red 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']  
  Message At 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}