PACIO Transitions of Care Implementation Guide
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Example Condition: OT Decondition Problem List

Generated Narrative: Condition

ResourceCondition "OT-ProblemList-Decondition"

Profile: US Core Condition Problems and Health Concerns Profile

Condition Asserted Date: 2024-04-30 15:40:00-0400

clinicalStatus: Active (Condition Clinical Status Codes#active)

verificationStatus: Confirmed (ConditionVerificationStatus#confirmed)

category: Power of muscles in lower half of the body (International Classification of Functioning, Disability and Health#b7303), Problem List Item (US Core Condition Category Extension Codes#problem-list-item), Functional Status (US Core Category#functional-status)

code: Physical deconditioning (finding) (SNOWMED CT#31031000119102)

bodySite: Entire lower body (body structure) (SNOWMED CT#362875007)

subject: Patient/Example-Smith-Johnson-Patient1 " SMITH-JOHNSON"

onset: 2024-04-26 15:40:00-0400

recordedDate: 2024-04-30 15:40:00-0400

asserter: PractitionerRole/Role-OT-JenCadbury

evidence

detail: Observation/BSJ-MDS-ShortWalk1

evidence

detail: Observation/BSJ-MDS-SitStand1

evidence

detail: Observation/BSJ-MDS-SitUp1

note: The weakness in the patient's lower extremities is secondary to deconditioning. According to the report from Neurology, patient did not have motor or sensory deficits below upper chest. High rehab potential.