Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s authorized representative, or patient’s healthcare provider that could identify a need, problem, or condition.

Data Element
Functional Status
Description (*Please confirm or update this field for the new USCDI version*)

Assessment of a person’s ability to perform activities of daily living and activities across other situations and settings.

Examples include but are not limited to Functional Assessment Standardized Items (FASI) and Timed Up and Go (TUG).

Applicable Vocabulary Standard(s)

Applicable Standards (*Please confirm or update this field for the new USCDI version*)
  • Logical Observation Identifiers Names and Codes (LOINC®)

View guidance on Applicable Vocabulary Standards and versioning.
Submitted By: Holly Miller, MD / MedAllies
Data Element Information
Data Element Description Assessment is a data class comprised of many tools used clinically to evaluate patient status, risks and capabilities.
Use Case Description(s)
Use Case Description We are proposing “Assessment” as a USCDI data class to serve as a repository for any standardized assessment instrument. There are thousands of assessment instruments in use across clinical settings, public health providers, payors, and researchers.
As one example, the CMS Data Element Library (DEL: Home - Data Element Library (cms.gov)) is an example of multiple standardized data elements used in the federally mandated assessment instruments by LTPAC (Long-Term and Post-Acute Care) providers who collectively provide care to over 7 million Medicare Beneficiaries per year. Because these assessments are required for payment and quality reporting, they are collected by the more than 15,000 Skilled Nursing Facilities (SNFs), 11,000 Home Health Agencies (HHAs), 4,600 Hospice Care agencies, 1,100 Inpatient Rehabilitation Facilities (IRFs), and 400 Long-Term Care Hospitals (LTCHs). These standardized data are collected and submitted to CMS as required by these entities. Most of these data elements are mapped to LOINC and some are mapped to C-CDA templates.
The DEL incorporates only a tiny percentage of standardized assessments currently in use; and the use of standardized assessments is universal in health care.
Estimate the breadth of applicability of the use case(s) for this data element This data class pertains to most or all patients, providers or requestors.
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) LOINC, SNOMED-CT
https://loinc.org/; https://www.snomed.org/
Additional Specifications N/A
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None
Restrictions on Use (e.g. licensing, user fees) None
Privacy and Security Concerns None
Estimate of Overall Burden This would vary depending on the specific assessment instrument and how it is used.
Other Implementation Challenges Unknown

Comment

Submitted by suchen on

Functional status with needs beyond post acute care

Functional status assessments are commonly used in healthcare to document a patient’s baseline ability to manage daily routines and life activities. This assessment can be used as an indicator of quality of life (QOL) and help guide delivering patient-centered care. Functional status assessments are used broadly in healthcare, and can be used to:
* screen initially for problems, as well monitor the patient over time
* assess how a disease impacts a patient’s baseline functional status and their overall ability to tolerate certain therapies during serious illness

Functional status assessments can be generic or disease specific. For instance, in oncology, the Eastern Cooperative Oncology Group (ECOG) Performance Status assists in determining a patient’s potential chemotherapy tolerance.

A plethora of functional status assessment tools have been created to assist clinical management and are used broadly in medicine in fields such as oncology, palliative care, surgery, orthopedics, geriatrics, psychiatry, neurology, physical medicine and rehabilitation, nursing, etc. Achieving optimal patient outcomes for health and well-being requires an understanding of factors that affect quality of life (QOL), such as the ability of patients to perform basic activities and participate in life situations.

Please see attachment with similar prior submission regarding need for standardized "functional status" data.

This comment is made on behalf of CodeX (Common Oncology Data Elements eXtensions), a member-driven HL7 FHIR Accelerator community of professional medical societies, health systems, industry and others seeking to achieve interoperability via the mCODE (minimal Common Oncology Data Elements) standard in order to drive step-change improvements in cancer patient care and research.

Functional Status Assessment _ USCDI Version 3 Proposal.docx

Log in or register to post comments

FormGuide

Help

1. Optional: Background Text / Cover Letter

The "Optional Background Text / Cover Letter" field provides space for additional context or introductory information related to your comment.

If you wish to provide context, explanation, or an introduction to your comment, enter this information in the field labeled "Optional Background Text / Cover Letter." This is entirely optional and is most useful when submitting multiple related comments or when additional background would help reviewers understand your feedback.

If you are only commenting on a single data class or element, you may leave this field blank.

2. Select the Data Class

To specify which data class your comment addresses:

  1. In the "Data Class" drop-down menu, select the appropriate data class you want to comment on.
  2. If you are providing a general comment that is not specific to a data element, select "General" from the options. Comments with this designation will be displayed on the USCDI landing page.
  3. Note that the Data Class field will automatically populate based on your current location in the platform:
    1. If you are on a data class page, the field will be set to that specific data class
    2. If you are on a data element page, the corresponding data class will be pre-selected
       

3. Select the Data Element

To specify which data element your comment addresses:

  1. In the "Data Element" drop-down menu, select the specific data element you want to comment on.
  2. The drop-down menu will display only the elements available under the data class you selected in the previous step.
  3. You can use the search function within the drop-down to quickly locate a specific data element.
  4. If you are commenting on the data class itself rather than a specific element, you may leave this field blank.

Note: Comments on a specific data element will appear on the respective data element page, while comments on a data class (without a specific element selected) will appear on the landing page for that data class.
 

Data Class and Data Element

Fig 1 The "Data Class" and "Data Element" dropdown menus allow users to specify the exact content they wish to comment on.

4. Optional: Propose New Data Class or Element

If you cannot find the appropriate data class or element for your comment:

  1. Instead of clicking the "Comment On An Existing Data Class Or Element" button, click the adjacent button labeled "Propose a New Data Class or Data Element."
  2. This will redirect you to the ONDEC (ONC New Data Element and Class) Submission System.
  3. In the ONDEC system, follow the provided instructions to submit your proposal for a new data class or element.
  4. Once your proposal is submitted through ONDEC, it will be reviewed separately from the commenting process.
Propose New Data Class or Element

Fig 2 The "Propose a New Data Class or Data Element" button redirects users to the ONDEC Submission System for proposing new data elements not currently available in the system.

5. Complete the Comment Form

Fill out the required fields in the comment form:

Subject: Enter a brief, descriptive title that summarizes your comment. This helps reviewers quickly understand the nature of your feedback.

Comment: In this field, provide the full details of your comment or feedback. Be as clear and specific as possible about your suggestions, concerns, or observations. Include any relevant details that support your position.

6. Optional: Add Additional Comments

If you need to comment on multiple data classes or elements:

  1. After completing your first comment, click the link labeled "Comment on another data element" at the bottom of the form.
  2. A new comment section will appear, allowing you to enter details for your additional comment.
  3. For each additional comment, you must select the appropriate data class and data element from the drop-down menus.
  4. Complete the Subject and Comment fields for your additional comment.
  5. Repeat this process for each additional comment you wish to submit.

Fig 3 The "Comment on another data element" link enables users to create multiple comments addressing different elements within a single submission.

7. Optional: Upload Supporting Files

The platform allows you to upload supporting documentation to enhance your comment:

  • Locate the "File Upload" section at the bottom of the comment form.
  • Click to upload any files (such as PDFs or documents) that provide additional context, evidence, or clarification for your comment.

Important: If you have already entered your comments using the form fields, there is no need to upload duplicate content in PDF format. The file upload feature is intended for supplementary materials only. Please avoid uploading files that contain the same information already provided in your comment text.

Upload Supporting Files

Fig 4 The "File Upload" section permits users to attach supporting documentation that supplements their written comments.

8. Optional: Save and Exit

If you need to pause your work and return to complete your comment later:

  1. Click the "Save and Exit" button at the bottom of the form.
  2. Your comment will be saved as a draft that you can access and complete later.
  3. When you return to the platform, you will see a red triangle with an exclamation mark next to the “Return to saved Comment” button, indicating that you have saved comments in draft status.
  4. Click this button to continue working on your draft.
  5. You will be taken to a review page where you can:
    1. Select "Submit Comment" to officially submit your feedback.
    2. Click "Edit" to return to the comment form and make changes
    3. Select "Discard Draft" to delete the saved draft and start fresh

Fig 5 A red triangle with exclamation mark indicator appears next to the “Return to saved Comment” button when draft comments are saved in the system.

9. Review and Submit

Once you have completed your comment:

  1. Click the "Review and Submit" button at the bottom of the form.
  2. This will take you to a review screen displaying your comment(s) in full.
  3. Review all information for accuracy and completeness.
  4. On this review screen, you have three options: 
    1. Click "Submit Comment" to officially submit your feedback
    2. Click "Edit" to return to the comment form and make changes
    3. Click "Discard Draft" to delete the comment and start fresh
  5. The review screen also includes a "Print" button that allows you to create a printed copy of your comments for your records. 
  6. If you choose to submit, your comment will be recorded in the system and made available for review by the appropriate stakeholders.
Review and Submit

Fig 6 The review screen allows users to verify comment content and make any necessary modifications before final submission.

USCDI Comments

Close

Add a New Comment

Review comment and Submit

Edit
Comment #1
PDF, Doc, Docx
Max Size : 10 MB