Version 2.80

Term Description

Functional status assessment describes the patient's status of normal functioning at the time a care record was created. Functional statuses include information regarding the patient relative to ambulatory ability, mental status or competency, activities of daily living (ADLs) (i.e. bathing, dressing, feeding, grooming), home/living situation having an effect on the health status of the patient, ability to care for self, social activity (i.e. issues with social cognition, participation with friends and acquaintances other than family members), occupation activity (i.e. activities partly or directly related to working), housework or volunteering, family and home responsibilities or activities related to home and family, communication ability (i.e. issues with speech, writing or cognition required for communication), and perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance.

Fully-Specified Name

Component
Functional status assessment note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Long Common Name
Functional status assessment note
Short Name
Functional status note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.19
Last Updated
Version 2.67 (MIN)
Change Reason
Previous Releases: Based on Clinical LOINC Committee approval on 2/17/2012, "note" was added to the Component as the Kind of Document.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;
Order vs. Observation
Both
HL7® Attachment Structure
No implementation guide exists

Member of these Panels

LOINC Long Common Name
81898-9 Composite triage and nursing note - recommended IHE set
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
74449-0 Patient plan of care - recommended IHE set
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Funktionelle Statusbeurteilung - Notiz:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
el-GR Greek (Greece) Σημείωμα αξιολόγησης λειτουργικής κατάστασης:Εύρεση:Pt:{Ρυθμίσεις}:Doc:{Ρόλος}
Synonyms: Αξιολόγηση Εύρεση Κατάσταση Λειτουργική κατάσταση Σημείωμα αξιολόγησης Σημείωμα αξιολόγησης λειτουργικής κατάστασης Σημείωση
es-MX Spanish (Mexico) Nota de evaluación del estado funcional:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Stato funzionale, nota di valutazione:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di valutazione dello stato funzionale Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) beoordeling van functioneren:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 功能状态评估记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 功能（机能）状态（状况、情况）（评价、估计、估价、评论、估定、估算）记录;功能状况评估记录;功能情况评估记录 功能状况;功能情况 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 状况;情况 笔记;按语;注释;说明;票据;单据;证明书 评价;估计;估价;评论;估定;估算 评估（评价、估计、估价、评论、估定、估算）记录

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=47420-5