This Capability Statement defines the expected capabilities of a Personal Functioning and Engagement FHIR server conforming to the Personal Functioning and Engagement Implementation Guide.

An abstract profile representing the cross-cutting requirements for Personal Functioning and Engagement Observation instances. This profile is not intended to be used directly. Implementers should use specific profiles that layer these requirements on top of specific US Core Observation profiles.

An exchange of post-acute care observation for a patient. This profile is used for exchanging a single piece of observation data that resulted from a clinical test.

A point in time collection of post-acute care observations for a patient. This profile is used for exchanging a set of observation data collected through the use of a structured resource (e.g., assessment tool, instrument, or screen) with multiple questions.

An exchange of post-acute care condition encounter diagnosis for a patient. This profile is used for exchanging a condition encounter diagnosis.

An exchange of post-acute care condition, problem, or health concern for a patient. This profile is used for exchanging a problem list item or a health concern.

An exchange of post-acute care diagonistic report notes for a patient. This profile is used for exchanging diagnostic report notes, as opposed to laboratory notes.

An exchange of post-acute care goal for a patient. This profile is used for exchanging a personal functioning and engagement goal.

An exchange of a narrative summary regarding the most recent prior status immediately preceding the current admission, illness, or exacerbation for a patient. The use of this profile is encouraged in the absence of formal prior level assessments. For formal assessments conducted with for example, an assessment instrument, use the collection and single observation profiles defined in this IG to capture assessment data.

An exchange of post-acute care service request for a patient. This profile is used for exchanging service requests.

An exchange of post-acute care observation for a patient. This profile is used for exchanging an observation for a single question generally included in a structured resource (e.g., assessment tool, instrument, or screen).

A record of an assistive device (e.g., eyeglasses or hearing aid) being used by a patient during a post-acute care observation. This profile based on the DeviceUseStatement resource provides a way to include information about device usage during an assessment.

Associated with the Narrative History of Status profile to provide a high-level indication of assistance required for the person’s baseline ability (status immediately preceding the current admission, illness, or exacerbation for a patient). The CMS Assessment answer list LL4309-2 provides possible values for this extension.

Associated with the PAC Collection profile to point to a record indicating what healthcare-related assistive device was used by a patient during an observation. This extension leverages the DeviceUseStatement resource instead of Device resource so as to indicate appropriately a record of assistive device usage by a patient.

This extension is used to indicate the principal physical location where an observation event occurred.

This value set includes LOINC codes that represent patient observations regarding individual’s body structures.

This value set includes codes representing health and health-related domains into which functioning observations can be further categorized.

This value set includes LOINC codes that represent patient observations regarding individual’s communication.

This value set includes LOINC codes that represent patient observations regarding individual’s domestic life.

This value set includes LOINC codes that provide examples of observations within the scope of the Personal Functioning and Engagement IG.

This value set includes LOINC codes that represent patient observations regarding individual’s digestive, metabolic, and endocrine systems functioning.

This value set includes LOINC codes that represent patient observations regarding individual’s skin and related structures functioning.

This value set includes LOINC codes that represent patient observations regarding individual’s genitourinary and reproductive functioning.

This value set includes LOINC codes that represent patient goals regarding individual’s mobility.

This value set includes LOINC panel codes that are goals represent headers and sub-headers in CMS assessments and are tied to PFE collections.

This value set includes LOINC codes that represent patient goals regarding individual’s ability to perform self-care.

This value set includes LOINC codes that represent patient observations regarding individual’s ability to learn and apply knowledge.

This value set includes LOINC codes that represent patient observations regarding individual’s mental functioning.

This value set includes LOINC codes that represent patient observations regarding individual’s mobility.

This value set includes LOINC codes that represent patient observations regarding individual’s neuromusculoskeletal and movement related functioning.

This value set includes LOINC panel codes that represent headers and sub-headers in CMS assessments and are tied to PFE collections.

This value set includes LOINC codes that represent patient observations regarding the products and technology that affect their lives.

This value set includes LOINC codes that represent patient observations regarding individual’s ability to perform self-care.

This value set includes LOINC codes that represent clinicl test observations regarding individual’s sensory functioning and pain.

This value set includes LOINC codes that represent patient observations regarding individual’s sensory functioning and pain.

This value set includes LOINC codes that represent patient observations regarding individual’s structures involved in voice and speech.

This value set includes LOINC codes that represent patient observations regarding individual’s voice and speech functioning.

Includes codes representing health and health-related domains into which functioning observations can be further categorized.

Defines a specific code for the classification of patient observations regarding individual’s functioning and engagement.

Example Device: Bedside rails

Example Device: Eyeglasses

Example Device: Handle bars

Example Device: Hearing aid

Example Device: Raised toilet seat

Example Device: Rolling walker

Example Device: Walker

Example PFE Collection for hospital MMSE assessment

Example PFE Observation: Total score [MMSE]

Example PFE Collection for hospital MOCA assessment

Example PFE Observation: Total score [MoCA]

Example PFE Collection for SNF BIMS assessment

Example PFE Observation: Brief Interview for Mental Status - summary score [BIMS]

Example PFE Observation: Temporal orientation - current year [BIMS]

Example PFE Observation: Recall - bed [BIMS]

Example PFE Observation: Recall - blue [BIMS]

Example PFE Observation: Recall - sock [BIMS]

Example PFE Observation: Temporal orientation - current day of the week [BIMS]

Example PFE Observation: Temporal orientation - current month [BIMS]

Example PFE Observation: Repetition of three words # [BIMS]

Example PFE Collection for SNF BIMS assessment: recall

Example PFE Collection for SNF BIMS assessment: temporal

Example PFE Use of Device for eyeglasses

Example PFE Use of Device for hearing aid

Example PFE Collection for SNF CAM assessment

Example PFE Observation: Inattention in last 7 days [CAM.CMS]

Example PFE Observation: Disorganized thinking in last 7 days [CAM.CMS]

Example PFE Observation: Acute onset mental status change [CAM.CMS]

Example PFE Collection for resident mood interview

Example PFE Observation: Feeling tired or having little energy in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Observation: Poor appetite or overeating in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Feeling down, depressed or hopeless in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Observation: Trouble falling or staying asleep, or sleeping too much in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Trouble falling or staying asleep, or sleeping too much in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Observation: Feeling tired or having little energy in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Little interest or pleasure in doing things in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Little interest or pleasure in doing things in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Observation: Feeling down, depressed or hopeless in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Trouble concentrating on things, such as reading the newspaper or watching television in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Observation: Thoughts that you would be better off dead, or of hurting yourself in some way in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Observation: Feeling bad about yourself - or that you are a failure or have let yourself or your family down in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Poor appetite or overeating in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Observation: Trouble concentrating on things, such as reading the newspaper or watching television in last 2 weeks.presence [Reported PHQ-9 CMS]

Example PFE Observation: Feeling bad about yourself - or that you are a failure or have let yourself or your family down in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Observation: Mood interview total severity score [Reported PHQ-9 CMS]

Example PFE Observation: Thoughts that you would be better off dead, or of hurting yourself in some way in last 2 weeks.frequency [Reported PHQ-9 CMS]

Example PFE Collection of mobility observations for hospital admission

Example PFE Observation: Roll left and right - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Toilet transfer - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Car transfer - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Walk 10 feet - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Walk 50 feet with two turns - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Walk 150 feet - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Walking 10 feet on uneven surfaces - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: 1 step (curb) - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: 4 steps - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: 12 steps - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Picking up object - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Sit to lying - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Wheel 50 feet with two turns - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Wheel 150 feet - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Lying to sitting on side of bed - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Sit to stand - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Bed-to-chair transfer - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Use of Device for bedside rails

Example PFE Use of Device for walker

Example PFE Collection of mobility observations for hospital discharge

Example PFE Observation: Bed-to-chair transfer - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Toilet transfer - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Car transfer - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Walk 10 feet - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Walk 50 feet with two turns - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Roll left and right - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Walk 150 feet - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Walking 10 feet on uneven surfaces - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: 1 step (curb) - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: 4 steps - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: 12 steps - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Picking up object - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Wheel 50 feet with two turns - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Wheel 150 feet - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Sit to lying - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Lying to sitting on side of bed - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Sit to stand - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Use of Device for bedside rails

Example PFE Use of Device for rolling walker

Example PFE Use of Device for walker

Example PFE Use of Device for raised toilet seat

Example PFE Use of Device for handle bars

Example PFE Collection of self-care observations for SNF admission

Example PFE Observation: Toileting hygiene - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Shower/bathe self - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Upper body dressing - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Lower body dressing - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Putting on/taking off footwear - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Eating - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Observation: Oral hygiene - functional ability during 3 day assessment period [CMS Assessment]

Example PFE Narrative History of Status: History of Cognitive Function Narrative

Example PFE Narrative History of Status for mobility and self-care

Example Nested Personal Functioning and Engagement Collection, ie. a Collection of Collections

Example Organization: San Antonio General Hospital

Example Organization: Happy Nursing Facility

Example Organization: Sky Harbor Home Health Services

Example Location: San Antonio General Hospital

Example Location: Happy Nursing Facility

Example Location: Sky Harbor Home Health Services

Example Practitioner: Daniel Granger

Example Practitioner: Honey Jones

Example Practitioner: Jen Cadbury

Example Practitioner: Jenny Glass

Example Practitioner: Jill Bradley

Example Practitioner: John Smith

Example Practitioner: Luna Baskins

Example Practitioner: Nora Ologist

Example Practitioner: Ron Marble

Example Practitioner: Sally Smith

Example Practitioner: Scott Dumble

Example U.S. Core Questionaire Response: Minimum Data Set (MDS) admission mobility assessment

Example U.S. Core Questionaire Response: Minimum Data Set (MDS) discharge mobility assessment

Example U.S. Core Questionnaire Response: Mini-Mental State Examination [MMSE]

Example U.S. Core Questionnaire Response: Montreal Cognitive Assessment [MoCA]

Example U.S. Core Questionaire Response: Minimum Data Set (MDS) admission self-care assessment

Example U.S. Core Questionnaire Response: Brief interview for mental status [BIMS]

Example U.S. Core Questionnaire Response: Signs and Symptoms of Delirium (from CAM)

Example U.S. Core Questionnaire Response: Resident mood interview (PHQ-9) [Reported PHQ-9 CMS]

Example Practitioner Role: Audiologist

Example Practitioner Role: Occupational therapist

Example Practitioner Role: Occupational therapist

Example Practitioner Role: Physiotherapist

Example Practitioner Role: Physiotherapist

Example Practitioner Role: Physiotherapist

Example Practitioner Role: Speech and language therapist

Example Practitioner Role: Speech and language therapist

Example Practitioner Role: Speech and language therapist

Example PFE Clinical Test Observation for sensory functions and pain

Example US Core Patient: Betsy Smith-Johnson

Example Organization: Primary Care INC.

Example Organization: Neuro Care INC.

Example Location: Primary Care INC.

Example Location: Neuro Care INC.

Example Practitioner Role: Neurologist

Example Practitioner Role: Primary Care Physician