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
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MentalStatusObservation | Version: 2.1 | |||
Draft as of 2023-09-29 | Computable Name: MentalStatusObservation | |||
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.74:2015-08-01 |
The Mental Status Observation template represents an observation about mental status that can come from a broad range of subjective and objective information (including measured data) to address those categories described in the Mental Status Section. See also Assessment Scale Observation for specific collections of observations that together yield a summary evaluation of a particular condition.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange | ||
classCode | 1..1 | cs | Fixed Value: OBS | |
moodCode | 1..1 | cs | Fixed Value: EVN | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
extension | 1..1 | st | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | 1..1 | CD | ||
code | 1..1 | cs | Required Pattern: 8693-4 | |
codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
statusCode | 1..1 | CS | ||
code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | ||
value | C | 1..1 | ANY, BL, ED, ST, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). |
author | 0..* | AuthorParticipation | Base for all types and resources | |
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
entryRelationship:assessmentScale | 0..* | EntryRelationship | ||
typeCode | 1..1 | cs | Fixed Value: COMP | |
observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
referenceRange | 0..* | InfrastructureRoot | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange Base for all types and resources | |
@classCode | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Fixed Value: EVN | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | 1..1 | CD | Binding: ObservationType (extensible) | |
@code | 1..1 | cs | Required Pattern: 8693-4 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | ||
value | C | 1..1 | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). | |
value | ANY | |||
value | BL | |||
value | ED | |||
value | ST | |||
value | CD | |||
value | CV | |||
value | CE | |||
value | SC | |||
value | II | |||
value | TEL | |||
value | AD | |||
value | EN | |||
value | INT | |||
value | REAL | |||
value | PQ | |||
value | MO | |||
value | TS | |||
value | IVL_PQ | |||
value | IVL_TS | |||
value | PIVL_TS | |||
value | EIVL_TS | |||
value | SXPR_TS | |||
value | RTO_PQ_PQ | |||
author | 0..* | AuthorParticipation | Base for all types and resources | |
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
entryRelationship:assessmentScale | 0..* | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
referenceRange | 0..* | InfrastructureRoot | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
observationRange | 1..1 | ObservationRange | ||
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.code | extensible | ObservationType |
Observation.statusCode | required | ActStatus |
Observation.entryRelationship:assessmentScale.typeCode | required | Fixed Value: COMP |
Id | Grade | Path(s) | Details | Requirements |
1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.templateId:primary.nullFlavor | required | NullFlavor |
Observation.code | extensible | ObservationType |
Observation.code.nullFlavor | required | NullFlavor |
Observation.statusCode | required | ActStatus |
Observation.statusCode.nullFlavor | required | NullFlavor |
Observation.priorityCode | extensible | ActPriority |
Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066 ) |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.methodCode | extensible | ObservationMethod |
Observation.entryRelationship:assessmentScale.nullFlavor | required | NullFlavor |
Observation.entryRelationship:assessmentScale.typeCode | required | Fixed Value: COMP |
Observation.referenceRange.nullFlavor | required | NullFlavor |
Observation.referenceRange.typeCode | required | Fixed Value: REFV |
Id | Grade | Path(s) | Details | Requirements |
1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.Observation
Summary
Mandatory: 11 elements (1 nested mandatory element)
Fixed Value: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange | ||
classCode | 1..1 | cs | Fixed Value: OBS | |
moodCode | 1..1 | cs | Fixed Value: EVN | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
extension | 1..1 | st | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | 1..1 | CD | ||
code | 1..1 | cs | Required Pattern: 8693-4 | |
codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
statusCode | 1..1 | CS | ||
code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | ||
value | C | 1..1 | ANY, BL, ED, ST, CD, CV, CE, SC, II, TEL, AD, EN, INT, REAL, PQ, MO, TS, IVL_PQ, IVL_TS, PIVL_TS, EIVL_TS, SXPR_TS, RTO_PQ_PQ | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). |
author | 0..* | AuthorParticipation | Base for all types and resources | |
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
entryRelationship:assessmentScale | 0..* | EntryRelationship | ||
typeCode | 1..1 | cs | Fixed Value: COMP | |
observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
referenceRange | 0..* | InfrastructureRoot | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | CDAR2.Observation | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @classCode, @moodCode, @negationInd, realmCode, typeId, templateId, id, code, derivationExpr, text, statusCode, effectiveTime, priorityCode, repeatNumber, languageCode, value, interpretationCode, methodCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, referenceRange Base for all types and resources | |
@classCode | 1..1 | cs | Binding: ActClassObservation (required) Fixed Value: OBS | |
@moodCode | 1..1 | cs | Fixed Value: EVN | |
Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
@root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
@extension | 1..1 | st | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | 1..1 | CD | Binding: ObservationType (extensible) | |
@code | 1..1 | cs | Required Pattern: 8693-4 | |
@codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
@code | 1..1 | cs | Fixed Value: completed | |
effectiveTime | 1..1 | IVL_TS | ||
value | C | 1..1 | 1198-14271: If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). | |
value | ANY | |||
value | BL | |||
value | ED | |||
value | ST | |||
value | CD | |||
value | CV | |||
value | CE | |||
value | SC | |||
value | II | |||
value | TEL | |||
value | AD | |||
value | EN | |||
value | INT | |||
value | REAL | |||
value | PQ | |||
value | MO | |||
value | TS | |||
value | IVL_PQ | |||
value | IVL_TS | |||
value | PIVL_TS | |||
value | EIVL_TS | |||
value | SXPR_TS | |||
value | RTO_PQ_PQ | |||
author | 0..* | AuthorParticipation | Base for all types and resources | |
Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by profile:observation | |
entryRelationship:assessmentScale | 0..* | EntryRelationship | ||
@typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |
observation | 1..1 | AssessmentScaleObservation | Base for all types and resources | |
referenceRange | 0..* | InfrastructureRoot | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
observationRange | 1..1 | ObservationRange | ||
Documentation for this format |
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.code | extensible | ObservationType |
Observation.statusCode | required | ActStatus |
Observation.entryRelationship:assessmentScale.typeCode | required | Fixed Value: COMP |
Id | Grade | Path(s) | Details | Requirements |
1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Fixed Value: OBS |
Observation.templateId:primary.nullFlavor | required | NullFlavor |
Observation.code | extensible | ObservationType |
Observation.code.nullFlavor | required | NullFlavor |
Observation.statusCode | required | ActStatus |
Observation.statusCode.nullFlavor | required | NullFlavor |
Observation.priorityCode | extensible | ActPriority |
Observation.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066 ) |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.methodCode | extensible | ObservationMethod |
Observation.entryRelationship:assessmentScale.nullFlavor | required | NullFlavor |
Observation.entryRelationship:assessmentScale.typeCode | required | Fixed Value: COMP |
Observation.referenceRange.nullFlavor | required | NullFlavor |
Observation.referenceRange.typeCode | required | Fixed Value: REFV |
Id | Grade | Path(s) | Details | Requirements |
1198-14271 | warning | Observation.value | If xsi:type=“CD”, **SHOULD** contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). : | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
This structure is derived from CDAR2.Observation
Summary
Mandatory: 11 elements (1 nested mandatory element)
Fixed Value: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices: