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pending Template  Social History Observation

Template 2.16.840.1.113883.10.20.22.4.38 - SocialHistoryObservation
Id 2.16.840.1.113883.10.20.22.4.38
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Entry Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.38
Open/Closed Open (other than defined elements are allowed)
Description This Social History Observation defines the patient’s occupational, personal (e.g., lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity, and religious affiliation.
Used by / Uses
Used by / Uses 6 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.17 Containment SocialHistorySection Social History Section 2013‑01‑31
2.16.840.1.113883.10.20.22.1.2 link ContinuityofCareDocumentCCD Continuity of Care Document (CCD) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.3 link HistoryandPhysical History and Physical 2013‑01‑31
2.16.840.1.113883.10.20.22.1.4 link ConsultationNote Consultation Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.6 link ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.8 link DischargeSummary Discharge Summary 2013‑01‑31
Item DT Card Conf Description Label
cda:observation
(SocialHistoryObservation)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8550) such that it conf‑8550
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.38
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:8551). conf‑8551
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:8558). conf‑8558
treeblank treetree cda:originalText
0 .. 1 R This code SHOULD contain zero or one [0..1] originalText (CONF:19221). conf‑19221
treeblank treeblank treetree cda:reference
0 .. 1 R The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:19222).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
conf‑19222
treeblank treeblank treeblank treetree @value
0 .. 1  
  Schematron assert role red error
  test count(cda:code/cda:originalText/cda:reference[@value])=0 or starts-with(cda:code/cda:originalText/cda:reference/@value, '#')
  Message This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)
treetree cda:statusCode
1 .. 1 M SHALL contain exactly one [1..1] statusCode (CONF:8553). conf‑8553
treeblank treetree @code
1 .. 1 F completed
treetree cda:value
0 .. 1 R SHOULD contain zero or one [0..1] value (CONF:8559).

Observation/value can be any data type. Where Observation/value is a physical quantity, the unit of measure SHALL be expressed using a valid Unified Code for Units of Measure (UCUM) expression.
conf‑8559