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/2.16.840.1.113883.10.20.22.4.73 | Version: 2.2 | |||
Draft as of 2022-05-13 | Computable Name: CognitiveStatusProblemObservation | |||
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.73:2014-06-09 |
A cognitive status problem observation is a clinical statement that describes a patient’s cognitive condition, findings, or symptoms. Examples of cognitive problem observations are inability to recall, amnesia, dementia, and aggressive behavior.
A cognitive problem observation is a finding or medical condition. This is different from a cognitive result observation, which is a response to a question that provides insight into the patient’s cognitive status, judgement, comprehension ability, or response speed.
THIS TEMPLATE HAS BEEN DEPRECATED AND MAY BE DELETED FROM A FUTURE RELEASE OF THIS IMPLEMENTATION GUIDE. USE OF THIS TEMPLATE IS NOT RECOMMENDED.
Reason for deprecation: Cognitive Status Problem Observation has been merged, without loss of expressivity, into Mental Status Observation (2.16.840.1.113883.10.20.22.4.74).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Observation
Summary
Mandatory: 10 elements (1 nested mandatory element)
Slices
This structure defines the following Slices:
This structure is derived from CDAR2.Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | CDAR2.Observation | ||
classCode | 1..1 | code | Required Pattern: OBS | |
moodCode | 1..1 | code | Required Pattern: EVN | |
negationInd | 0..1 | boolean | Use negationInd="true" to indicate that the problem was not observed. | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.73 | |
extension | 1..1 | string | Required Pattern: 2014-06-09 | |
id | 1..* | II | ||
code | 1..1 | CD | ||
code | 0..1 | string | Required Pattern: 373930000 | |
text | 0..1 | ED | ||
reference | 0..1 | TEL | ||
value | I | 0..1 | uri | 1098-15534: SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15534). |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: completed | |
effectiveTime | 0..1 | IVL_TS | ||
low | 1..1 | TS | The value of effectiveTime/low represents onset date. | |
high | 0..1 | TS | If the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element. | |
value | 1..1 | CD | Binding: Problem (preferred) | |
methodCode | 0..* | CE | ||
Documentation for this format |
This structure is derived from CDAR2.Observation
Summary
Mandatory: 10 elements (1 nested mandatory element)
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 1..1 | CDAR2.Observation | ||
classCode | 1..1 | code | Required Pattern: OBS | |
moodCode | 1..1 | code | Required Pattern: EVN | |
negationInd | 0..1 | boolean | Use negationInd="true" to indicate that the problem was not observed. | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.73 | |
extension | 1..1 | string | Required Pattern: 2014-06-09 | |
id | 1..* | II | ||
code | 1..1 | CD | ||
code | 0..1 | string | Required Pattern: 373930000 | |
text | 0..1 | ED | ||
reference | 0..1 | TEL | ||
value | I | 0..1 | uri | 1098-15534: SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15534). |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: completed | |
effectiveTime | 0..1 | IVL_TS | ||
low | 1..1 | TS | The value of effectiveTime/low represents onset date. | |
high | 0..1 | TS | If the problem is resolved, record the resolution date in effectiveTime/high. If the problem is known to be resolved but the resolution date is not known, use @nullFlavor="UNK". If the problem is not resolved, do not include the high element. | |
value | 1..1 | CD | Binding: Problem (preferred) | |
methodCode | 0..* | CE | ||
Documentation for this format |
Snapshot View
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
Observation.classCode | required | Pattern: OBS |
Observation.templateId:primary.nullFlavor | required | NullFlavor |
Observation.code | extensible | ObservationType |
Observation.code.nullFlavor | required | NullFlavor |
Observation.text.nullFlavor | required | NullFlavor |
Observation.text.compression | required | CompressionAlgorithm |
Observation.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
Observation.text.reference.nullFlavor | required | NullFlavor |
Observation.text.reference.use | required | AddressUse |
Observation.statusCode | required | ActStatus |
Observation.statusCode.nullFlavor | required | NullFlavor |
Observation.effectiveTime.nullFlavor | required | NullFlavor |
Observation.priorityCode | extensible | ActPriority |
Observation.languageCode | required | HumanLanguage |
Observation.value | preferred | Problem |
Observation.interpretationCode | required | ObservationInterpretation |
Observation.methodCode | extensible | ObservationMethod |
Observation.subject.typeCode | required | Fixed Value: SBJ |
Observation.subject.contextControlCode | required | Fixed Value: OP |
Observation.subject.awarenessCode | extensible | TargetAwareness |
Observation.informant.typeCode | required | Fixed Value: INF |
Observation.informant.contextControlCode | required | Fixed Value: OP |
Observation.referenceRange.typeCode | required | Fixed Value: REFV |
Id | Grade | Path | Details | Requirements |
1098-15534 | error | Observation.text.reference.value | SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:1098-15534). : | |
obs-er-1 | error | Observation.entryRelationship | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |