PACIO Cognitive Status Implementation Guide
1.0.0 - STU 1

PACIO Cognitive Status Implementation Guide, published by HL7 Patient Care Work Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/fhir-pacio-cognitive-status/ and changes regularly. See the Directory of published versions

Resource Profile: PACIO Cognitive Status

Defining URL:http://hl7.org/fhir/us/pacio-cs/StructureDefinition/pacio-cs
Version:1.0.0
Name:CognitiveStatus
Title:PACIO Cognitive Status
Status:Active as of 2021-11-03T18:57:36+00:00
Definition:

An exchange of cognitive status observation for a patient. This profile is used for exchanging a single observation data generally included in a set of observation data collected through the use of a structured resource (e.g. assessment tool, instrument, or screen).

Publisher:HL7 Patient Care Work Group
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/us/pacio-cs/StructureDefinition/pacio-cs

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationMeasurements and simple assertions
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
... basedOn 0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Currently not used in CognitiveStatus.
... status 1..1codeShould have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
... Slices for category 1..*CodeableConceptA second category code may be used along with the code “functioning”. For example, for assessment tool/survey instrument observations use “survey” as a second code.
Slice: Unordered, Open by pattern:coding
.... category:functioning 1..1CodeableConceptClassification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... coding 1..*CodingCode defined by a terminology system
Required Pattern: At least the following
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
... code 1..1CodeableConceptFor a Post-Acute Care Assessment, should include a LOINC code and text for the question or concept name.
Binding: LOINCCodes (extensible)
... subject 1..1Reference(US Core Patient Profile)Should only reference a Patient resource.
... focus 0..*Reference(Resource)Currently not used in CognitiveStatus.
... encounter 0..1Reference(US Core Encounter Profile)Healthcare event during which this observation is made
... effective[x] 1..1dateTimeClinically relevant time/time-period for observation
... issued 0..1instantCurrently not used in CognitiveStatus.
... performer 1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] 0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodWhenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
... interpretation 0..*CodeableConceptCurrently not used in CognitiveStatus.
... bodySite 0..1CodeableConceptCurrently not used in CognitiveStatus.
... method 0..1CodeableConceptCurrently not used in CognitiveStatus.
... specimen 0..1Reference(Specimen)Currently not used in CognitiveStatus.
... device 0..1Reference(Device | DeviceMetric)Currently not used in CognitiveStatus.
... referenceRange 0..*BackboneElementCurrently not used in CognitiveStatus.
... hasMember 0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Currently not used in CognitiveStatus.
... derivedFrom S0..*Reference(SDC Questionnaire Response)Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component 0..*BackboneElementCurrently not used in CognitiveStatus.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationMeasurements and simple assertions
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Currently not used in CognitiveStatus.
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Currently not used in CognitiveStatus.
... status ?!Σ1..1codeShould have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..*CodeableConceptA second category code may be used along with the code “functioning”. For example, for assessment tool/survey instrument observations use “survey” as a second code.
Slice: Unordered, Open by pattern:coding
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:functioning 1..1CodeableConceptClassification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ1..*CodingCode defined by a terminology system

Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptFor a Post-Acute Care Assessment, should include a LOINC code and text for the question or concept name.
Binding: LOINCCodes (extensible)
... subject Σ1..1Reference(US Core Patient Profile)Should only reference a Patient resource.
... focus Σ0..*Reference(Resource)Currently not used in CognitiveStatus.
... encounter Σ0..1Reference(US Core Encounter Profile)Healthcare event during which this observation is made
... effective[x] Σ1..1dateTimeClinically relevant time/time-period for observation
... issued Σ0..1instantCurrently not used in CognitiveStatus.
... performer Σ1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] ΣI0..1Whenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason I0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptCurrently not used in CognitiveStatus.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptCurrently not used in CognitiveStatus.
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptCurrently not used in CognitiveStatus.
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Currently not used in CognitiveStatus.
... device 0..1Reference(Device | DeviceMetric)Currently not used in CognitiveStatus.
... referenceRange I0..*BackboneElementCurrently not used in CognitiveStatus.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Currently not used in CognitiveStatus.
... derivedFrom SΣ0..*Reference(SDC Questionnaire Response)Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component Σ0..*BackboneElementCurrently not used in CognitiveStatus.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationMeasurements and simple assertions
... event-location 0..1Reference(US Core Location Profile)An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
... derivedFrom Σ0..*Reference(SDC Questionnaire Response)Should point back to the SDC QuestionnaireResponse that this resource is derived from.

doco Documentation for this format

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationMeasurements and simple assertions
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
... basedOn 0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Currently not used in CognitiveStatus.
... status 1..1codeShould have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
... Slices for category 1..*CodeableConceptA second category code may be used along with the code “functioning”. For example, for assessment tool/survey instrument observations use “survey” as a second code.
Slice: Unordered, Open by pattern:coding
.... category:functioning 1..1CodeableConceptClassification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... coding 1..*CodingCode defined by a terminology system
Required Pattern: At least the following
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
... code 1..1CodeableConceptFor a Post-Acute Care Assessment, should include a LOINC code and text for the question or concept name.
Binding: LOINCCodes (extensible)
... subject 1..1Reference(US Core Patient Profile)Should only reference a Patient resource.
... focus 0..*Reference(Resource)Currently not used in CognitiveStatus.
... encounter 0..1Reference(US Core Encounter Profile)Healthcare event during which this observation is made
... effective[x] 1..1dateTimeClinically relevant time/time-period for observation
... issued 0..1instantCurrently not used in CognitiveStatus.
... performer 1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] 0..1Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, PeriodWhenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
... interpretation 0..*CodeableConceptCurrently not used in CognitiveStatus.
... bodySite 0..1CodeableConceptCurrently not used in CognitiveStatus.
... method 0..1CodeableConceptCurrently not used in CognitiveStatus.
... specimen 0..1Reference(Specimen)Currently not used in CognitiveStatus.
... device 0..1Reference(Device | DeviceMetric)Currently not used in CognitiveStatus.
... referenceRange 0..*BackboneElementCurrently not used in CognitiveStatus.
... hasMember 0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Currently not used in CognitiveStatus.
... derivedFrom S0..*Reference(SDC Questionnaire Response)Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component 0..*BackboneElementCurrently not used in CognitiveStatus.

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*ObservationMeasurements and simple assertions
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Currently not used in CognitiveStatus.
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Currently not used in CognitiveStatus.
... status ?!Σ1..1codeShould have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: ObservationStatus (required): Codes providing the status of an observation.

... Slices for category 1..*CodeableConceptA second category code may be used along with the code “functioning”. For example, for assessment tool/survey instrument observations use “survey” as a second code.
Slice: Unordered, Open by pattern:coding
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


.... category:functioning 1..1CodeableConceptClassification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ1..*CodingCode defined by a terminology system

Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptFor a Post-Acute Care Assessment, should include a LOINC code and text for the question or concept name.
Binding: LOINCCodes (extensible)
... subject Σ1..1Reference(US Core Patient Profile)Should only reference a Patient resource.
... focus Σ0..*Reference(Resource)Currently not used in CognitiveStatus.
... encounter Σ0..1Reference(US Core Encounter Profile)Healthcare event during which this observation is made
... effective[x] Σ1..1dateTimeClinically relevant time/time-period for observation
... issued Σ0..1instantCurrently not used in CognitiveStatus.
... performer Σ1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... value[x] ΣI0..1Whenever possible should use the CodeableConcept datatype to provide a suitable code to define the concept for the observation data. As for values like an assessment score or roll-up value, the datatype for this element should be determined by Observation.code. However, for values that are ordinal, may use the CodeableConcept datatype along with the Ordinal Value Extension.
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason I0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptCurrently not used in CognitiveStatus.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptCurrently not used in CognitiveStatus.
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptCurrently not used in CognitiveStatus.
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Currently not used in CognitiveStatus.
... device 0..1Reference(Device | DeviceMetric)Currently not used in CognitiveStatus.
... referenceRange I0..*BackboneElementCurrently not used in CognitiveStatus.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Currently not used in CognitiveStatus.
... derivedFrom SΣ0..*Reference(SDC Questionnaire Response)Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component Σ0..*BackboneElementCurrently not used in CognitiveStatus.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
Observation.languagepreferredCommonLanguages
Max Binding: AllLanguages
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
Observation.codeextensibleLOINCCodes
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes