PACIO Cognitive Status Implementation Guide
1.0.0 - STU 1 United States of America flag

PACIO Cognitive Status Implementation Guide, published by HL7 Patient Care Work Group. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. 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 Collection

Official URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/pacio-csc Version: 1.0.0
Active as of 2024-11-05 Computable Name: CognitiveStatusCollection

A point in time collection of cognitive status observations for a patient. This profile is used for exchanging a set of observation data collected through the use of a structured resource (e.g. assessment tool, instrument, or screen).

Usage:

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..* Observation Measurements and simple assertions
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
.... device-use S 0..* Reference(Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/device-patient-used
... basedOn 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Currently not used in CognitiveStatusCollection.
... partOf 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in CognitiveStatusCollection.
... Slices for category 1..* CodeableConcept A 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..1 CodeableConcept Classification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
... code 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (extensible)
... subject 1..1 Reference(US Core Patient Profile) Should only reference a Patient resource.
... focus 0..* Reference(Resource) Currently not used in CognitiveStatusCollection.
... encounter 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] 1..1 Clinical relevant time for an assessment such as cognitive assessments performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued 0..1 instant Currently not used in CognitiveStatusCollection.
... 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..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period If used, should use the CodeableConcept datatype whenever possible to provide a suitable code to define the concept for the observation data. When capturing a collection of related observations, typically this field is not used. If the outcome of an assessment includes one or more summary scores, leave this field unused and use the 'hasMember' field to point to one or more Observation resources with each of which has a score provided in the 'value' field.
... dataAbsentReason 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
... interpretation 0..* CodeableConcept Currently not used in CognitiveStatusCollection.
... bodySite 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
... method 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
... specimen 0..1 Reference(Specimen) Currently not used in CognitiveStatusCollection.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in CognitiveStatusCollection.
... referenceRange 0..* BackboneElement Currently not used in CognitiveStatusCollection.
... hasMember S 0..* Reference(PACIO Cognitive Status) Each cognitive status observation in the collection.
... derivedFrom S 0..* Reference(SDC Questionnaire Response) Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component 0..* BackboneElement Currently not used in CognitiveStatusCollection.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
http://hl7.org/fhir/us/pacio-cs/ValueSet/pacio-cat-vs
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
.... device-use S 0..* Reference(Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/device-patient-used
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in CognitiveStatusCollection.
... status ?!Σ 1..1 code Should have the value 'final' when all the observatons are 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..* CodeableConcept A 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..1 CodeableConcept Classification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... coding Σ 1..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
... code Σ 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (extensible)
... subject Σ 1..1 Reference(US Core Patient Profile) Should only reference a Patient resource.
... focus Σ 0..* Reference(Resource) Currently not used in CognitiveStatusCollection.
... encounter Σ 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] Σ 1..1 Clinical relevant time for an assessment such as cognitive assessments performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Currently not used in CognitiveStatusCollection.
... performer Σ 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] ΣC 0..1 If used, should use the CodeableConcept datatype whenever possible to provide a suitable code to define the concept for the observation data. When capturing a collection of related observations, typically this field is not used. If the outcome of an assessment includes one or more summary scores, leave this field unused and use the 'hasMember' field to point to one or more Observation resources with each of which has a score provided in the 'value' field.
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason C 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..* CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... bodySite 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Currently not used in CognitiveStatusCollection.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in CognitiveStatusCollection.
... referenceRange C 0..* BackboneElement Currently not used in CognitiveStatusCollection.
obs-3: Must have at least a low or a high or text
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... hasMember SΣ 0..* Reference(PACIO Cognitive Status) Each cognitive status observation in the collection.
... derivedFrom SΣ 0..* Reference(SDC Questionnaire Response) Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component Σ 0..* BackboneElement Currently not used in CognitiveStatusCollection.
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
http://hl7.org/fhir/us/pacio-cs/ValueSet/pacio-cat-vs
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
.... device-use S 0..* Reference(Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/device-patient-used
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Currently not used in CognitiveStatusCollection.
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in CognitiveStatusCollection.
... status ?!Σ 1..1 code Should have the value 'final' when all the observatons are 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..* CodeableConcept A 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..1 CodeableConcept Classification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 1..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
... code Σ 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (extensible)
... subject Σ 1..1 Reference(US Core Patient Profile) Should only reference a Patient resource.
... focus Σ 0..* Reference(Resource) Currently not used in CognitiveStatusCollection.
... encounter Σ 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] Σ 1..1 Clinical relevant time for an assessment such as cognitive assessments performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Currently not used in CognitiveStatusCollection.
... performer Σ 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] ΣC 0..1 If used, should use the CodeableConcept datatype whenever possible to provide a suitable code to define the concept for the observation data. When capturing a collection of related observations, typically this field is not used. If the outcome of an assessment includes one or more summary scores, leave this field unused and use the 'hasMember' field to point to one or more Observation resources with each of which has a score provided in the 'value' field.
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason C 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..* CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Currently not used in CognitiveStatusCollection.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in CognitiveStatusCollection.
... referenceRange C 0..* BackboneElement Currently not used in CognitiveStatusCollection.
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

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


.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember SΣ 0..* Reference(PACIO Cognitive Status) Each cognitive status observation in the collection.
... derivedFrom SΣ 0..* Reference(SDC Questionnaire Response) Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component Σ 0..* BackboneElement Currently not used in CognitiveStatusCollection.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..* CodeableConcept High, 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

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
http://hl7.org/fhir/us/pacio-cs/ValueSet/pacio-cat-vs
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..* Observation Measurements and simple assertions
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
.... device-use S 0..* Reference(Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/device-patient-used
... basedOn 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Currently not used in CognitiveStatusCollection.
... partOf 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in CognitiveStatusCollection.
... Slices for category 1..* CodeableConcept A 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..1 CodeableConcept Classification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
... code 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (extensible)
... subject 1..1 Reference(US Core Patient Profile) Should only reference a Patient resource.
... focus 0..* Reference(Resource) Currently not used in CognitiveStatusCollection.
... encounter 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] 1..1 Clinical relevant time for an assessment such as cognitive assessments performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued 0..1 instant Currently not used in CognitiveStatusCollection.
... 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..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period If used, should use the CodeableConcept datatype whenever possible to provide a suitable code to define the concept for the observation data. When capturing a collection of related observations, typically this field is not used. If the outcome of an assessment includes one or more summary scores, leave this field unused and use the 'hasMember' field to point to one or more Observation resources with each of which has a score provided in the 'value' field.
... dataAbsentReason 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
... interpretation 0..* CodeableConcept Currently not used in CognitiveStatusCollection.
... bodySite 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
... method 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
... specimen 0..1 Reference(Specimen) Currently not used in CognitiveStatusCollection.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in CognitiveStatusCollection.
... referenceRange 0..* BackboneElement Currently not used in CognitiveStatusCollection.
... hasMember S 0..* Reference(PACIO Cognitive Status) Each cognitive status observation in the collection.
... derivedFrom S 0..* Reference(SDC Questionnaire Response) Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component 0..* BackboneElement Currently not used in CognitiveStatusCollection.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
http://hl7.org/fhir/us/pacio-cs/ValueSet/pacio-cat-vs
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
.... device-use S 0..* Reference(Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/device-patient-used
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in CognitiveStatusCollection.
... status ?!Σ 1..1 code Should have the value 'final' when all the observatons are 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..* CodeableConcept A 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..1 CodeableConcept Classification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... coding Σ 1..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
... code Σ 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (extensible)
... subject Σ 1..1 Reference(US Core Patient Profile) Should only reference a Patient resource.
... focus Σ 0..* Reference(Resource) Currently not used in CognitiveStatusCollection.
... encounter Σ 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] Σ 1..1 Clinical relevant time for an assessment such as cognitive assessments performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Currently not used in CognitiveStatusCollection.
... performer Σ 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] ΣC 0..1 If used, should use the CodeableConcept datatype whenever possible to provide a suitable code to define the concept for the observation data. When capturing a collection of related observations, typically this field is not used. If the outcome of an assessment includes one or more summary scores, leave this field unused and use the 'hasMember' field to point to one or more Observation resources with each of which has a score provided in the 'value' field.
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason C 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..* CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... bodySite 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Currently not used in CognitiveStatusCollection.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in CognitiveStatusCollection.
... referenceRange C 0..* BackboneElement Currently not used in CognitiveStatusCollection.
obs-3: Must have at least a low or a high or text
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... hasMember SΣ 0..* Reference(PACIO Cognitive Status) Each cognitive status observation in the collection.
... derivedFrom SΣ 0..* Reference(SDC Questionnaire Response) Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component Σ 0..* BackboneElement Currently not used in CognitiveStatusCollection.
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
http://hl7.org/fhir/us/pacio-cs/ValueSet/pacio-cat-vs
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C 0..* Observation Measurements and simple assertions
obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present
obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the observation event occurred.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-cs/StructureDefinition/event-location
.... device-use S 0..* Reference(Use of Device) An extension to indicate a record of assistive device usage by a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/device-patient-used
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Currently not used in CognitiveStatusCollection.
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in CognitiveStatusCollection.
... status ?!Σ 1..1 code Should have the value 'final' when all the observatons are 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..* CodeableConcept A 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..1 CodeableConcept Classification of type of observation
Binding: PACIO Functioning Category Value Set (extensible)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 1..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-cs/CodeSystem/pacio-cat-cs
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
... code Σ 1..1 CodeableConcept For a Post-Acute Care structured assessment resource such as an instrument or screen, use a LOINC code to identify the instrument/screen name or panel/section title to indicate the kind of assessment.
Binding: LOINCCodes (extensible)
... subject Σ 1..1 Reference(US Core Patient Profile) Should only reference a Patient resource.
... focus Σ 0..* Reference(Resource) Currently not used in CognitiveStatusCollection.
... encounter Σ 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] Σ 1..1 Clinical relevant time for an assessment such as cognitive assessments performed with structured evaluation tools is the time the evaluation occurs, i.e., when the clinician obtains the answers entered in the tool. However, the only timing available may be when then tool is completed by the clinician. That timing is generally documented as a point in time (dateTime).
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Currently not used in CognitiveStatusCollection.
... performer Σ 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] ΣC 0..1 If used, should use the CodeableConcept datatype whenever possible to provide a suitable code to define the concept for the observation data. When capturing a collection of related observations, typically this field is not used. If the outcome of an assessment includes one or more summary scores, leave this field unused and use the 'hasMember' field to point to one or more Observation resources with each of which has a score provided in the 'value' field.
.... valueQuantity Quantity
.... valueCodeableConcept CodeableConcept
.... valueString string
.... valueBoolean boolean
.... valueInteger integer
.... valueRange Range
.... valueRatio Ratio
.... valueSampledData SampledData
.... valueTime time
.... valueDateTime dateTime
.... valuePeriod Period
... dataAbsentReason C 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..* CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..* Annotation Comments about the observation
... bodySite 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1 CodeableConcept Currently not used in CognitiveStatusCollection.
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1 Reference(Specimen) Currently not used in CognitiveStatusCollection.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in CognitiveStatusCollection.
... referenceRange C 0..* BackboneElement Currently not used in CognitiveStatusCollection.
obs-3: Must have at least a low or a high or text
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

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


.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember SΣ 0..* Reference(PACIO Cognitive Status) Each cognitive status observation in the collection.
... derivedFrom SΣ 0..* Reference(SDC Questionnaire Response) Should point back to the SDC QuestionnaireResponse that this resource is derived from.
... component Σ 0..* BackboneElement Currently not used in CognitiveStatusCollection.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 CodeableConcept Type of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ 0..1 Actual component result
..... valueQuantity Quantity
..... valueCodeableConcept CodeableConcept
..... valueString string
..... valueBoolean boolean
..... valueInteger integer
..... valueRange Range
..... valueRatio Ratio
..... valueSampledData SampledData
..... valueTime time
..... valueDateTime dateTime
..... valuePeriod Period
.... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..* CodeableConcept High, 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

Terminology Bindings

PathConformanceValueSetURI
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Observation.statusrequiredObservationStatus
http://hl7.org/fhir/ValueSet/observation-status|4.0.1
from the FHIR Standard
Observation.categorypreferredObservationCategoryCodes
http://hl7.org/fhir/ValueSet/observation-category
from the FHIR Standard
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
http://hl7.org/fhir/us/pacio-cs/ValueSet/pacio-cat-vs
from this IG
Observation.codeextensibleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard
Observation.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Observation.methodexampleObservationMethods
http://hl7.org/fhir/ValueSet/observation-methods
from the FHIR Standard
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
http://hl7.org/fhir/ValueSet/referencerange-meaning
from the FHIR Standard
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
http://hl7.org/fhir/ValueSet/referencerange-appliesto
from the FHIR Standard
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/observation-codes
from the FHIR Standard
Observation.component.dataAbsentReasonextensibleDataAbsentReason
http://hl7.org/fhir/ValueSet/data-absent-reason
from the FHIR Standard
Observation.component.interpretationextensibleObservationInterpretationCodes
http://hl7.org/fhir/ValueSet/observation-interpretation
from the FHIR Standard

 

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