Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Mental Status Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusSection Version: 2.1
Draft as of 2023-09-29 Computable Name: MentalStatusSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.56:2015-08-01

The Mental Status Section contains observations and evaluations related to a patient’s psychological and mental competency and deficits including, but not limited to any of the following types of information:

  • Appearance (e.g., unusual grooming, clothing or body modifications)
  • Attitude (e.g., cooperative, guarded, hostile)
  • Behavior/psychomotor (e.g., abnormal movements, eye contact, tics)
  • Mood and affect (e.g., anxious, angry, euphoric)
  • Speech and Language (e.g., pressured speech, perseveration)
  • Thought process (e.g., logic, coherence)
  • Thought content (e.g., delusions, phobias)
  • Perception (e.g., voices, hallucinations)
  • Cognition (e.g., memory, alertness/consciousness, attention, orientation) which were included in Cognitive Status Observation in earlier publications of C-CDA.
  • Insight and judgment (e.g., understanding of condition, decision making)

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.56
..... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1csRequired Pattern: 10190-7
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:organizer, profile:observation
.... entry:mentalStatusOrganizer 0..*Entry
..... organizer 1..1MentalStatusOrganizerBase for all types and resources
.... entry:mentalStatusObs 0..*Entry
..... observation 1..1MentalStatusObservationBase for all types and resources
.... entry:assessmentScale 0..*Entry
..... observation 1..1AssessmentScaleObservationBase for all types and resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.56
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 10190-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:organizer, profile:observation
.... entry:mentalStatusOrganizer 0..*Entry
..... organizer 1..1MentalStatusOrganizerBase for all types and resources
.... entry:mentalStatusObs 0..*Entry
..... observation 1..1MentalStatusObservationBase for all types and resources
.... entry:assessmentScale 0..*Entry
..... observation 1..1AssessmentScaleObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... @ID 0..1xs:ID
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.56
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 10190-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:organizer, profile:observation
.... entry:mentalStatusOrganizer 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 1..1MentalStatusOrganizerBase for all types and resources
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:mentalStatusObs 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1MentalStatusObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:assessmentScale 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1AssessmentScaleObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.entry:mentalStatusOrganizer.nullFlavorrequiredNullFlavor
Section.entry:mentalStatusOrganizer.typeCoderequiredXActRelationshipEntry
Section.entry:mentalStatusObs.nullFlavorrequiredNullFlavor
Section.entry:mentalStatusObs.typeCoderequiredXActRelationshipEntry
Section.entry:assessmentScale.nullFlavorrequiredNullFlavor
Section.entry:assessmentScale.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredNullFlavor

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Section

Summary

Mandatory: 9 elements (3 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:extension, value:root
  • The element Section.entry is sliced based on the values of profile:organizer, profile:observation

Differential View

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.56
..... extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CE
.... code 1..1csRequired Pattern: 10190-7
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:organizer, profile:observation
.... entry:mentalStatusOrganizer 0..*Entry
..... organizer 1..1MentalStatusOrganizerBase for all types and resources
.... entry:mentalStatusObs 0..*Entry
..... observation 1..1MentalStatusObservationBase for all types and resources
.... entry:assessmentScale 0..*Entry
..... observation 1..1AssessmentScaleObservationBase for all types and resources

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.56
..... @extension 1..1stRequired Pattern: 2015-08-01
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 10190-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ST
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:organizer, profile:observation
.... entry:mentalStatusOrganizer 0..*Entry
..... organizer 1..1MentalStatusOrganizerBase for all types and resources
.... entry:mentalStatusObs 0..*Entry
..... observation 1..1MentalStatusObservationBase for all types and resources
.... entry:assessmentScale 0..*Entry
..... observation 1..1AssessmentScaleObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... @ID 0..1xs:ID
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 1..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.56
..... @extension 1..1stRequired Pattern: 2015-08-01
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 10190-7
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntrySlice: Unordered, Open by profile:organizer, profile:observation
.... entry:mentalStatusOrganizer 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 1..1MentalStatusOrganizerBase for all types and resources
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:mentalStatusObs 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1MentalStatusObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entry:assessmentScale 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1AssessmentScaleObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredNullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.entry:mentalStatusOrganizer.nullFlavorrequiredNullFlavor
Section.entry:mentalStatusOrganizer.typeCoderequiredXActRelationshipEntry
Section.entry:mentalStatusObs.nullFlavorrequiredNullFlavor
Section.entry:mentalStatusObs.typeCoderequiredXActRelationshipEntry
Section.entry:assessmentScale.nullFlavorrequiredNullFlavor
Section.entry:assessmentScale.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredNullFlavor

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Section

Summary

Mandatory: 9 elements (3 nested mandatory elements)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:extension, value:root
  • The element Section.entry is sliced based on the values of profile:organizer, profile:observation

 

Other representations of profile: CSV, Excel