Consolidated CDA Release 2.2
2.2 - CI Build

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

Resource Profile: MentalStatusSection - Detailed Descriptions

Definitions for the 2.16.840.1.113883.10.20.22.2.56 resource profile.

1. Section
Control1..1
2. Section.ID
Control0..1
Typestring
3. Section.nullFlavor
Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
4. Section.classCode
Control1..1
BindingThe codes SHALL be taken from http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer
Typecode
Default ValueDOCSECT
Fixed ValueDOCSECT
5. Section.moodCode
Control1..1
BindingThe codes SHALL be taken from ActMood
Typecode
Default ValueEVN
Fixed ValueEVN
6. Section.templateId
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
SlicingThis element introduces a set of slices on Section.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ extension
  • ,
  • value @ root
7. Section.templateId:primary
SliceNameprimary
Definition

When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question

Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
Requirements

SHALL contain exactly one [1..1] templateId (CONF:1198-28293) such that it

8. Section.templateId:primary.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
9. Section.templateId:primary.assigningAuthorityName
Definition

A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.

Control0..1
Typestring
10. Section.templateId:primary.displayable
Definition

Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).

Control0..1
Typeboolean
11. Section.templateId:primary.root
Definition

A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.56" (CONF:1198-28294).

Pattern Value2.16.840.1.113883.10.20.22.2.56
12. Section.templateId:primary.extension
Definition

A character string as a unique identifier within the scope of the identifier root.

Control1..1
Typestring
Requirements

SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32793).

Pattern Value2015-08-01
13. Section.id
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/II
14. Section.code
Control1..1
BindingThe codes SHALL be taken from DocumentSectionType; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
Requirements

SHALL contain exactly one [1..1] code (CONF:1198-28295).

15. Section.code.nullFlavor
Definition

If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.

Control0..1
BindingThe codes SHALL be taken from NullFlavor
Typecode
16. Section.code.code
Definition

The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.

Control1..1
Typestring
Requirements

This code SHALL contain exactly one [1..1] @code="10190-7" Mental Status (CONF:1198-28296).

Pattern Value10190-7
17. Section.code.codeSystem
Definition

Specifies the code system that defines the code.

Control1..1
Typestring
Requirements

This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:1198-30826).

Pattern Value2.16.840.1.113883.6.1
18. Section.code.codeSystemName
Definition

The common name of the coding system.

Control0..1
Typestring
19. Section.code.codeSystemVersion
Definition

If applicable, a version descriptor defined specifically for the given code system.

Control0..1
Typestring
20. Section.code.displayName
Definition

A name or title for the code, under which the sending system shows the code value to its users.

Control0..1
Typestring
21. Section.code.sdtcValueSet
Definition

The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.

Control0..1
Typestring
22. Section.code.sdtcValueSetVersion
Definition

The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.

Control0..1
Typestring
23. Section.code.originalText
Definition

The text or phrase used as the basis for the coding.

Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ED
24. Section.code.qualifier
Definition

Specifies additional codes that increase the specificity of the the primary code.

Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/CR
25. Section.code.translation
Definition

A set of other concept descriptors that translate this concept descriptor into other code systems.

Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/CD
26. Section.title
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ST
Requirements

SHALL contain exactly one [1..1] title (CONF:1198-28297).

27. Section.text
Control1..1
Typexhtml
Must Supporttrue
Requirements

SHALL contain exactly one [1..1] text (CONF:1198-28298).

28. Section.confidentialityCode
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
29. Section.languageCode
Control0..1
BindingThe codes SHALL be taken from HumanLanguage
Typehttp://hl7.org/fhir/cda/StructureDefinition/CS
30. Section.subject
Control0..1
TypeElement
31. Section.subject.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationTargetSubject
Typecode
Default ValueSBJ
Fixed ValueSBJ
32. Section.subject.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
33. Section.subject.awarenessCode
Control0..1
BindingThe codes SHALL be taken from TargetAwareness; other codes may be used where these codes are not suitable
Typehttp://hl7.org/fhir/cda/StructureDefinition/CE
34. Section.subject.relatedSubject
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedSubject
35. Section.author
Control0..*
Typehttp://hl7.org/fhir/cda/StructureDefinition/Author
36. Section.informant
Control0..*
TypeElement
37. Section.informant.typeCode
Control1..1
BindingThe codes SHALL be taken from ParticipationInformationGenerator
Typecode
Default ValueINF
Fixed ValueINF
38. Section.informant.contextControlCode
Control1..1
BindingThe codes SHALL be taken from ContextControl
Typecode
Default ValueOP
Fixed ValueOP
39. Section.informant.assignedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/AssignedEntity
40. Section.informant.relatedEntity
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RelatedEntity
41. Section.entry
Control0..*
TypeElement
InvariantsDefined on this element
only-one-statement: 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)
SlicingThis element introduces a set of slices on Section.entry. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • profile @ organizer
  • ,
  • profile @ observation
42. Section.entry.typeCode
Control1..1
Typecode
Default ValueCOMP
43. Section.entry.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
44. Section.entry.observation
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation
45. Section.entry.regionOfInterest
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
46. Section.entry.observationMedia
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
47. Section.entry.substanceAdministration
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
48. Section.entry.supply
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
49. Section.entry.procedure
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
50. Section.entry.encounter
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
51. Section.entry.organizer
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
52. Section.entry.act
Control0..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
53. Section.entry:mentalStatusOrganizer
SliceNamementalStatusOrganizer
Control0..*
TypeElement
Requirements

MAY contain zero or more [0..*] entry (CONF:1198-28301) such that it

InvariantsDefined on this element
only-one-statement: 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)
54. Section.entry:mentalStatusOrganizer.typeCode
Control1..1
Typecode
Default ValueCOMP
55. Section.entry:mentalStatusOrganizer.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
56. Section.entry:mentalStatusOrganizer.observation
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation
57. Section.entry:mentalStatusOrganizer.regionOfInterest
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
58. Section.entry:mentalStatusOrganizer.observationMedia
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
59. Section.entry:mentalStatusOrganizer.substanceAdministration
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
60. Section.entry:mentalStatusOrganizer.supply
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
61. Section.entry:mentalStatusOrganizer.procedure
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
62. Section.entry:mentalStatusOrganizer.encounter
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
63. Section.entry:mentalStatusOrganizer.organizer
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer(MentalStatusOrganizer)
Requirements

SHALL contain exactly one [1..1] Mental Status Organizer (V3) (identifier: urn:hl7ii:2. 16.840.1.113883.10.20.22.4.75:2015-08-01) (CONF:1198-28302).

64. Section.entry:mentalStatusOrganizer.act
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
65. Section.entry:mentalStatusObs
SliceNamementalStatusObs
Control0..*
TypeElement
Requirements

MAY contain zero or more [0..*] entry (CONF:1198-28305) such that it

InvariantsDefined on this element
only-one-statement: 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)
66. Section.entry:mentalStatusObs.typeCode
Control1..1
Typecode
Default ValueCOMP
67. Section.entry:mentalStatusObs.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
68. Section.entry:mentalStatusObs.observation
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation(MentalStatusObservation)
Requirements

SHALL contain exactly one [1..1] Mental Status Observation (V3) (identifier: urn:hl7ii: 2.16.840.1.113883.10.20.22.4.74:2015-08-01) (CONF:1198-28306).

69. Section.entry:mentalStatusObs.regionOfInterest
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
70. Section.entry:mentalStatusObs.observationMedia
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
71. Section.entry:mentalStatusObs.substanceAdministration
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
72. Section.entry:mentalStatusObs.supply
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
73. Section.entry:mentalStatusObs.procedure
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
74. Section.entry:mentalStatusObs.encounter
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
75. Section.entry:mentalStatusObs.organizer
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
76. Section.entry:mentalStatusObs.act
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
77. Section.entry:assessmentScale
SliceNameassessmentScale
Control0..*
TypeElement
Requirements

MAY contain zero or more [0..*] entry (CONF:1198-28313) such that it

InvariantsDefined on this element
only-one-statement: 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)
78. Section.entry:assessmentScale.typeCode
Control1..1
Typecode
Default ValueCOMP
79. Section.entry:assessmentScale.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
80. Section.entry:assessmentScale.observation
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Observation(AssessmentScaleObservation)
Requirements

SHALL contain exactly one [1..1] Assessment Scale Observation (identifier: urn:oid:2.16 .840.1.113883.10.20.22.4.69) (CONF:1198-28314).

81. Section.entry:assessmentScale.regionOfInterest
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
82. Section.entry:assessmentScale.observationMedia
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
83. Section.entry:assessmentScale.substanceAdministration
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
84. Section.entry:assessmentScale.supply
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Supply
85. Section.entry:assessmentScale.procedure
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Procedure
86. Section.entry:assessmentScale.encounter
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Encounter
87. Section.entry:assessmentScale.organizer
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Organizer
88. Section.entry:assessmentScale.act
Control0..0
Typehttp://hl7.org/fhir/cda/StructureDefinition/Act
89. Section.component
Control0..*
TypeElement
90. Section.component.typeCode
Definition

Drawn from concept domain DocumentSectionType

Control1..1
Typecode
Default ValueCOMP
Fixed ValueCOMP
91. Section.component.contextConductionInd
Control1..1
Typeboolean
Default Valuetrue
92. Section.component.section
Control1..1
Typehttp://hl7.org/fhir/cda/StructureDefinition/Section