Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.56 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: MentalStatusSection | |||
Other Identifiers: : 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 patients 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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Section
Summary
Mandatory: 8 elements (3 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | CDAR2.Section | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.56 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 10190-7 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ED | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Element | Slice: Unordered, Open by profile:organizer, profile:observation | |
entry:mentalStatusOrganizer | 0..* | Element | ||
organizer | 1..1 | MentalStatusOrganizer | ||
entry:mentalStatusObs | 0..* | Element | ||
observation | 1..1 | MentalStatusObservation | ||
entry:assessmentScale | 0..* | Element | ||
observation | 1..1 | AssessmentScaleObservation | ||
Documentation for this format |
This structure is derived from CDAR2.Section
Summary
Mandatory: 8 elements (3 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | CDAR2.Section | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:extension, value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.56 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 10190-7 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ED | ||
text | 1..1 | xhtml | ||
Slices for entry | 0..* | Element | Slice: Unordered, Open by profile:organizer, profile:observation | |
entry:mentalStatusOrganizer | 0..* | Element | ||
organizer | 1..1 | MentalStatusOrganizer | ||
entry:mentalStatusObs | 0..* | Element | ||
observation | 1..1 | MentalStatusObservation | ||
entry:assessmentScale | 0..* | Element | ||
observation | 1..1 | AssessmentScaleObservation | ||
Documentation for this format |
Snapshot View
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
Section.nullFlavor | required | NullFlavor |
Section.classCode | required | Fixed Value: DOCSECT |
Section.moodCode | required | Fixed Value: EVN |
Section.templateId:primary.nullFlavor | required | NullFlavor |
Section.code | extensible | DocumentSectionType |
Section.code.nullFlavor | required | NullFlavor |
Section.languageCode | required | HumanLanguage |
Section.subject.typeCode | required | Fixed Value: SBJ |
Section.subject.contextControlCode | required | Fixed Value: OP |
Section.subject.awarenessCode | extensible | TargetAwareness |
Section.informant.typeCode | required | Fixed Value: INF |
Section.informant.contextControlCode | required | Fixed Value: OP |
Id | Grade | Path | Details | Requirements |
only-one-statement | error | Section.entry | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
only-one-statement | error | Section.entry:mentalStatusOrganizer | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
only-one-statement | error | Section.entry:mentalStatusObs | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
only-one-statement | error | Section.entry:assessmentScale | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |