PACIO Functional Performance Implementation Guide - Local Development build (v1.0.0). See the Directory of published versions
A large number and variety of assessment and observation instruments exist for assessing patient post-acute status in care settings. The following instruments have been analyzed for the purposes of providing implementation guidance and exchange of post-acute status. Standardized instruments that assess post-acute function fall into three broad categories based on use of standardized code systems.
Representative examples of each of these categories are provided in the following sections to guide implementers.
The following are examples of fully codified assessments:
COGNITIVE TESTS/SCREENS | LOINC |
---|---|
Confusion Assessment Method (CAM) | 52495-9 Confusion Assessment Method (CAM) 52738-2 Inattention 52739-0 Disorganized thinking 52740-8 Altered level of consciousness/alertness 52741-6 Psychomotor retardation |
Brief Interview for Mental Status (BIMS) | 52491-8 Brief Interview for Mental Status 52731-7 Repetition of Three Words. Number of words repeated after first attempt 54510-3 Temporal Orientation (orientation to year, month, and day) 52732-5 Able to report correct year 52733-3 Able to report correct month 54609-3 Able to report correct day of the week 52493-4 Recall 52735-8 Able to recall "sock" 52736-6 Able to recall "blue" 52737-4 Able to recall "bed" 54614-3 BIMS Summary Score |
Patient Health Questionnaire (PHQ) | 58120-7 Patient Health Questionnaire 2 item (PHQ-2) [PHQ.CMS] 55758-7 Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 54635-8 Patient Mood Interview (PHQ-2 to 9) 44261-6 Patient Health Questionnaire 9 item (PHQ-9) total score [Reported] 54657-2 Staff assessment of resident mood (PHQ-9-OV) [Observed PHQ-9 CMS] 54677-0 Staff assessment of resident mood total severity score [Observed PHQ-9 CMS] 89206-7 Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen] 89204-2 Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] |
Assessments that have LOINC codes for representing the instrument should be used for exchanging the instrument and result. Additional ‘meta data’ fields, such as author can be mapped using QuestionnaireResponse.
MoCA is provided as an example:
Montreal Cognitive Assessment (MoCA) | 72133-2 Montreal Cognitive Assessment [MoCA] 72172-0 Total score [MoCA] |
Some assessments do not have any codes associated with them. In this case, the individual data elements contained in the assessment instrument can be mapped to QuestionnaireResponse fields.
The Brief Cognitive Assessment Tool (BCAT) is included here as an example:
BCAT Fields | Mapping | Reference Mapping | Values |
---|---|---|---|
Name | QuestionnaireResponse.Subject | patient.name | |
DOB | QuestionnaireResponse.Subject | patient.birthDate | |
Gender | QuestionnaireResponse.Subject | patient.gender | AdministrativeGender (required) |
Education | Observation.component | 91694-0, LL836-8 | |
Examiner | QuestionnaireResponse.author | Reference to Practitioner/role | |
Today's Date | QuestionnaireResponse.authored ('dateTime' type) | ||
Total Score | Observation.value | Not contained in QuestionareResponse | |
referenceRange | Observation.ReferenceRange | Not part of BCAT form but needed for interpreting total score. |
Codes for Education: