This page is part of the PACIO Personal Functioning and Engagement Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Structured Data Capture

In many cases, clinicians use formal, structured instruments to capture details on a patient’s functioning and engagement. These include

• long forms required by payers that cover a broad range of domains, e.g., the Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI).
• shorter assessments that target specific areas such as the Montreal Cognitive Assessment (MoCA) or the swallowing panel that is part of the American Speech-Language-Hearing Association (ASHA) National Outcomes Measurement System (NOMS) program.

The Structured Data Capture FHIR IG provides a methodology for capturing this information within FHIR both in its raw and its discrete structured form. This page provides guidance on how tools like the SDC Questionnaire and US Core QuestionnaireResponse resources may be used with this IG.

Codified Representation

Standardized instruments fall into two broad categories based on use of standardized code systems.

1. Fully Codified – These instruments have standardized terminology associated with them, meaning the entire instrument can be modelled.
2. Partially Codified – These instruments generally have standardized question and answer pairs and a code to describe the instrument and total score. However, critical meta data or other information may only be found on the assessment itself. For example, the MoCA has codes for only the summary score and not the component questions.

Representative examples of each of these categories are provided in the following sections to guide implementers.

Fully Codified Assessments

The following are examples of fully codified assessments. QuestionnaireResponse representations of these assessments can be fully mapped to structured observation resources defined in this IG.

Tool	LOINC Codes
ASHA NOMS Functional Communication Measure - Swallowing panel	99852-6 NOMS Functional Communication Measure (FCM): Swallowing    99853-4 What modified diet is recommended for the individual to swallow solids safely?    99854-2 What modified liquid is recommended for the individual to swallow safely?    99855-9 What percentage of the individual's daily diet is delivered through non-oral means in order to maintain adequate nutrition and hydration?    99856-7 How often does the individual exhibit difficulties with oral containment or secretion management?    99857-5 How often does the individual require supervision/assistance at meal time due to swallowing safety?    99858-3 Functional Communication Measure - Swallowing score [ASHA NOMS]
Brief Interview for Mental Status (BIMS) (QuestionnaireResponse)	52491-8 Brief Interview for Mental Status (example)    52731-7 Repetition of Three Words. Number of words repeated after first attempt (example)    54510-3 Temporal Orientation (orientation to year, month, and day)      52732-5 Able to report correct year (example)      52733-3 Able to report correct month (example)      54609-3 Able to report correct day of the week (example)    52493-4 Recall      52735-8 Able to recall "sock" (example)      52736-6 Able to recall "blue" (example)      52737-4 Able to recall "bed" (example)    54614-3 BIMS Summary Score (example)
Self-care subset of MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set [CMS Assessment]	90540-6 Self-Care - Interim Performance    95019-6 Eating    95018-8 Oral hygiene    95017-0 Toileting hygiene

Partially Codified Assessments

Not all assessment tools have standardized codes for all of their questions. For example. the MoCA has chosen to have a coded representation for the summary score, not the individual questions, which may involve the patient drawing or performing other tasks. In cases like this, QuestionnaireResponses may not be fully mapped to structured observations, meaning that some information remains only in the QuestionnaireResponse instance, or on the paper form.

Montreal Cognitive Assessment (MoCA) (QuestionnaireResponse)

72133-2 Montreal Cognitive Assessment [MoCA] (example)    72172-0 Total score [MoCA] (example)

Structural Details For Display

In order to reduce the complexity of the observation structure, this IG only allows a single level of nesting for observations: collections contain a single flat list of observations. However, this means that some of the structure of the assessment is not represented, such as the BIMS grouper for “Temporal Orientation (orientation to year, month, and day)”. For systems wishing to display the complete structure, the QuestionnaireResponse instance can be used to identify the complete structure.