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 Narrative History of Cognitive Status

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

An exchange of summary observation regarding the most recent prior level of cognitive function immediately preceding the current admission, illness, or exacerbation for a patient. The use of this profile is encouraged in the absence of formal prior level of cognitive assessments. For formal assessments conducted with for example, an assessment instrument, use the Cognitive Status Collection and Cognitive Status profiles to capture assessment data.

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
.... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... basedOn 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Currently not used in PriorLevelOfCognitiveFunction.
... partOf 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in PriorLevelOfCognitiveFunction.
... Slices for category 1..* CodeableConcept Classification of type of observation
Slice: Ordered, 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 Type of observation (code / type)
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11332-4
..... display 1..1 string Representation defined by the system
Fixed Value: History of Cognitive Function Narrative
... subject 1..1 Reference(US Core Patient Profile) Who and/or what the observation is about
... focus 0..* Reference(Resource) Currently not used in PriorLevelOfCognitiveFunction.
... encounter 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued 0..1 instant Currently not used in PriorLevelOfCognitiveFunction.
... 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] 1..1 string Unstructured summary of cognitive status observation for the patient. (Strongly encouraged until more structured method is established)
... interpretation 0..* CodeableConcept Currently not used in PriorLevelOfCognitiveFunction.
... bodySite 0..1 CodeableConcept Currently not used in PriorLevelOfCognitiveFunction.
... method 0..1 CodeableConcept Currently not used in PriorLevelOfCognitiveFunction.
... specimen 0..1 Reference(Specimen) Currently not used in PriorLevelOfCognitiveFunction.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in PriorLevelOfCognitiveFunction.
... referenceRange 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
... hasMember 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... derivedFrom 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... component 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
http://hl7.org/fhir/us/pacio-cs/ValueSet/pacio-cat-vs
from this IG
Observation.coderequiredPattern: LOINC Code 11332-4("History of Cognitive Function Narrative")
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
.... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in PriorLevelOfCognitiveFunction.
... status ?!Σ 1..1 code Should 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..* CodeableConcept Classification of type of observation
Slice: Ordered, 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 Type of observation (code / type)
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11332-4
..... display 1..1 string Representation defined by the system
Fixed Value: History of Cognitive Function Narrative
... subject Σ 1..1 Reference(US Core Patient Profile) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) Currently not used in PriorLevelOfCognitiveFunction.
... encounter Σ 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] Σ 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Currently not used in PriorLevelOfCognitiveFunction.
... 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 1..1 string Unstructured summary of cognitive status observation for the patient. (Strongly encouraged until more structured method is established)
... interpretation 0..* CodeableConcept Currently not used in PriorLevelOfCognitiveFunction.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


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

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

... specimen 0..1 Reference(Specimen) Currently not used in PriorLevelOfCognitiveFunction.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in PriorLevelOfCognitiveFunction.
... referenceRange C 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
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 Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... component Σ 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
.... 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

PathConformanceValueSet / CodeURI
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.coderequiredPattern: LOINC Code 11332-4("History of Cognitive Function Narrative")
http://hl7.org/fhir/ValueSet/observation-codes
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
.... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... 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 PriorLevelOfCognitiveFunction.
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in PriorLevelOfCognitiveFunction.
... status ?!Σ 1..1 code Should 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..* CodeableConcept Classification of type of observation
Slice: Ordered, 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 Type of observation (code / type)
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... 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://loinc.org
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11332-4
..... display 1..1 string Representation defined by the system
Fixed Value: History of Cognitive Function Narrative
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject Σ 1..1 Reference(US Core Patient Profile) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) Currently not used in PriorLevelOfCognitiveFunction.
... encounter Σ 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] Σ 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Currently not used in PriorLevelOfCognitiveFunction.
... 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 1..1 string Unstructured summary of cognitive status observation for the patient. (Strongly encouraged until more structured method is established)
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

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

... specimen 0..1 Reference(Specimen) Currently not used in PriorLevelOfCognitiveFunction.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in PriorLevelOfCognitiveFunction.
... referenceRange C 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
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 Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... component Σ 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
.... 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

PathConformanceValueSet / CodeURI
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.coderequiredPattern: LOINC Code 11332-4("History of Cognitive Function Narrative")
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
.... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... basedOn 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Currently not used in PriorLevelOfCognitiveFunction.
... partOf 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in PriorLevelOfCognitiveFunction.
... Slices for category 1..* CodeableConcept Classification of type of observation
Slice: Ordered, 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 Type of observation (code / type)
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11332-4
..... display 1..1 string Representation defined by the system
Fixed Value: History of Cognitive Function Narrative
... subject 1..1 Reference(US Core Patient Profile) Who and/or what the observation is about
... focus 0..* Reference(Resource) Currently not used in PriorLevelOfCognitiveFunction.
... encounter 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued 0..1 instant Currently not used in PriorLevelOfCognitiveFunction.
... 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] 1..1 string Unstructured summary of cognitive status observation for the patient. (Strongly encouraged until more structured method is established)
... interpretation 0..* CodeableConcept Currently not used in PriorLevelOfCognitiveFunction.
... bodySite 0..1 CodeableConcept Currently not used in PriorLevelOfCognitiveFunction.
... method 0..1 CodeableConcept Currently not used in PriorLevelOfCognitiveFunction.
... specimen 0..1 Reference(Specimen) Currently not used in PriorLevelOfCognitiveFunction.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in PriorLevelOfCognitiveFunction.
... referenceRange 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
... hasMember 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... derivedFrom 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... component 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
Observation.category:functioningextensiblePACIOFunctioningCategoryVS
http://hl7.org/fhir/us/pacio-cs/ValueSet/pacio-cat-vs
from this IG
Observation.coderequiredPattern: LOINC Code 11332-4("History of Cognitive Function Narrative")
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
.... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in PriorLevelOfCognitiveFunction.
... status ?!Σ 1..1 code Should 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..* CodeableConcept Classification of type of observation
Slice: Ordered, 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 Type of observation (code / type)
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11332-4
..... display 1..1 string Representation defined by the system
Fixed Value: History of Cognitive Function Narrative
... subject Σ 1..1 Reference(US Core Patient Profile) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) Currently not used in PriorLevelOfCognitiveFunction.
... encounter Σ 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] Σ 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Currently not used in PriorLevelOfCognitiveFunction.
... 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 1..1 string Unstructured summary of cognitive status observation for the patient. (Strongly encouraged until more structured method is established)
... interpretation 0..* CodeableConcept Currently not used in PriorLevelOfCognitiveFunction.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


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

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

... specimen 0..1 Reference(Specimen) Currently not used in PriorLevelOfCognitiveFunction.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in PriorLevelOfCognitiveFunction.
... referenceRange C 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
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 Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... component Σ 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
.... 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

PathConformanceValueSet / CodeURI
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.coderequiredPattern: LOINC Code 11332-4("History of Cognitive Function Narrative")
http://hl7.org/fhir/ValueSet/observation-codes
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
.... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... 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 PriorLevelOfCognitiveFunction.
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Currently not used in PriorLevelOfCognitiveFunction.
... status ?!Σ 1..1 code Should 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..* CodeableConcept Classification of type of observation
Slice: Ordered, 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 Type of observation (code / type)
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... 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://loinc.org
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11332-4
..... display 1..1 string Representation defined by the system
Fixed Value: History of Cognitive Function Narrative
..... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text 0..1 string Plain text representation of the concept
... subject Σ 1..1 Reference(US Core Patient Profile) Who and/or what the observation is about
... focus Σ 0..* Reference(Resource) Currently not used in PriorLevelOfCognitiveFunction.
... encounter Σ 0..1 Reference(US Core Encounter Profile) Healthcare event during which this observation is made
... effective[x] Σ 1..1 Clinically relevant time/time-period for observation
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant Currently not used in PriorLevelOfCognitiveFunction.
... 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 1..1 string Unstructured summary of cognitive status observation for the patient. (Strongly encouraged until more structured method is established)
... dataAbsentReason C 0..1 CodeableConcept Why the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

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


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

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

... specimen 0..1 Reference(Specimen) Currently not used in PriorLevelOfCognitiveFunction.
... device 0..1 Reference(Device | DeviceMetric) Currently not used in PriorLevelOfCognitiveFunction.
... referenceRange C 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
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 Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Currently not used in PriorLevelOfCognitiveFunction.
... component Σ 0..* BackboneElement Currently not used in PriorLevelOfCognitiveFunction.
.... 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

PathConformanceValueSet / CodeURI
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.coderequiredPattern: LOINC Code 11332-4("History of Cognitive Function Narrative")
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

 

Other representations of profile: CSV, Excel, Schematron