Consolidated CDA (C-CDA)
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Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: MentalStatusObservation - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the MentalStatusObservation logical model.

Guidance on how to interpret the contents of this table can be found here

0. Observation
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
should-author: SHOULD contain author (author.exists())
2. Observation.templateId
Control1..?
SlicingThis element introduces a set of slices on Observation.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 4. Observation.templateId:mental-status-obs
    Slice Namemental-status-obs
    Control1..1
    6. Observation.templateId:mental-status-obs.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.74
    8. Observation.templateId:mental-status-obs.extension
    Control1..?
    Pattern Value2024-05-01
    10. Observation.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-14249).

    Fixed ValueOBS
    12. Observation.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: HL7ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-14250).

    Fixed ValueEVN
    14. Observation.id
    Comments

    SHALL contain at least one [1..*] id (CONF:1198-14257).

    Control1..?
    16. Observation.code
    ShortMental Status
    18. Observation.code.code
    Control1..?
    Pattern Value8693-4
    20. Observation.code.codeSystem
    ShortLOINC
    Control1..?
    Pattern Value2.16.840.1.113883.6.1
    22. Observation.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    24. Observation.text.reference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    26. Observation.statusCode
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:1198-14254).

    Control1..?
    28. Observation.statusCode.code
    Comments

    This statusCode SHALL contain exactly one [1..1] @code="completed" Completed (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14 STATIC) (CONF:1198-19092).

    Control1..?
    Fixed Valuecompleted
    30. Observation.effectiveTime
    Comments

    SHALL contain exactly one [1..1] effectiveTime (CONF:1198-14261).

    Control1..?
    32. Observation.value
    Comments

    SHALL contain exactly one [1..1] value (CONF:1198-14263).

    Control1..1
    SlicingThis element introduces a set of slices on Observation.value. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • type @ $this
    • 34. Observation.value:code
      Slice Namecode
      Control0..1
      BindingThe codes SHOULD be taken from Mental Status Observation .
      (preferred to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1240.1)
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/CD
      36. Observation.author
      Comments

      SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-14266).

      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
      38. Observation.entryRelationship
      SlicingThis element introduces a set of slices on Observation.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • profile @ observation
      • 40. Observation.entryRelationship:assessmentScale
        Slice NameassessmentScale
        Short𝗨𝗦𝗖𝗗𝗜: Mental/Cognitive Status
        Comments

        MAY contain zero or more [0..*] entryRelationship (CONF:1198-14469) such that it

        Control0..*
        42. Observation.entryRelationship:assessmentScale.typeCode
        Comments

        SHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-14595).

        Fixed ValueCOMP
        44. Observation.entryRelationship:assessmentScale.observation
        Comments

        SHALL contain exactly one [1..1] Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69) (CONF:1198-14470).

        Control1..?
        Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Assessment Scale Observation)
        46. Observation.referenceRange
        ShortThe referenceRange could be used to represent normal or expected capability for the mental function being evaluated.
        Comments

        MAY contain zero or more [0..*] referenceRange (CONF:1198-14267).