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/2.16.840.1.113883.10.20.22.4.74 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: MentalStatusObservation | |||
Other Identifiers: : 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
Summary
Mandatory: 16 elements (2 nested mandatory elements)
Structures
This structure refers to these other structures:
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 | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | 1..1 | CD | ||
code | 1..1 | string | Required Pattern: 373930000 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem | |
translation:cognitiveFunction | 1..1 | CD | ||
code | 1..1 | string | Required Pattern: 75275-8 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: completed | |
effectiveTime | 1..1 | IVL_TS | ||
value | I | 1..1 | BL, ED, ED, 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 | ||
Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
entryRelationship:assessmentScale | 0..* | Element | ||
typeCode | 1..1 | code | Required Pattern: COMP | |
observation | 1..1 | AssessmentScaleObservation | ||
referenceRange | 0..* | Element | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
Documentation for this format |
This structure is derived from CDAR2.Observation
Summary
Mandatory: 16 elements (2 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.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 | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.74 | |
extension | 1..1 | string | Required Pattern: 2015-08-01 | |
id | 1..* | II | ||
code | 1..1 | CD | ||
code | 1..1 | string | Required Pattern: 373930000 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.96 | |
Slices for translation | 0..* | CD | Slice: Unordered, Open by value:code, value:codeSystem | |
translation:cognitiveFunction | 1..1 | CD | ||
code | 1..1 | string | Required Pattern: 75275-8 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: completed | |
effectiveTime | 1..1 | IVL_TS | ||
value | I | 1..1 | BL, ED, ED, 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 | ||
Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation | |
entryRelationship:assessmentScale | 0..* | Element | ||
typeCode | 1..1 | code | Required Pattern: COMP | |
observation | 1..1 | AssessmentScaleObservation | ||
referenceRange | 0..* | Element | The referenceRange could be used to represent normal or expected capability for the mental function being evaluated. | |
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.code.translation:cognitiveFunction.nullFlavor | required | NullFlavor |
Observation.statusCode | required | ActStatus |
Observation.statusCode.nullFlavor | required | NullFlavor |
Observation.priorityCode | extensible | ActPriority |
Observation.languageCode | required | HumanLanguage |
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 |
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). : | |
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 | |
obs-er-1 | error | Observation.entryRelationship:assessmentScale | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |