PACIO Transitions of Care Implementation Guide
1.0.0-ballot - STU 1 Ballot United States of America flag

This page is part of the PACIO Transitions of Care Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. No current official version has been published yet. For a full list of available versions, see the Directory of published versions

Example Condition: OT Decondition Problem List

Page standards status: Informative

Generated Narrative: Condition OT-ProblemList-Decondition

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

clinicalStatus: Active

verificationStatus: Confirmed

category: Problem List Item

code: Physical deconditioning (finding)

bodySite: Entire lower body (body structure)

subject: Smith-Johnson, Betsy Female, DoB: 1958-11-01 ( http://hl7.org/fhir/sid/us-medicare#United States Medicare Number#10A3D58WH1600)

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

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

asserter: PractitionerRole Occupational Therapist

evidence

detail: Observation Walk 50 feet with two turns - functional goal during assessment period [CMS Assessment]

evidence

detail: Observation Sit to stand - functional goal during assessment period [CMS Assessment]

evidence

detail: Observation Lying to sitting on side of bed - functional goal during assessment period [CMS Assessment]

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.