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pending Template  Functional Status Result Observation

Template 2.16.840.1.113883.10.20.22.4.67 - FunctionalStatusResultObservation
Id 2.16.840.1.113883.10.20.22.4.67
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 2.16.840.1.113883.10.20.22.4.67
Open/Closed Open (other than defined elements are allowed)
Description This clinical statement represents details of an evaluation or assessment of a patient's functional status. The evaluation may include assessment of a patient's language, vision, hearing, activities of daily living, behavior, general function, mobility, and self-care status. The statement, if present, will include supporting caregivers, non-medical devices, and the time period for which the evaluation and assessment were performed
Used by / Uses
Used by / Uses 10 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.14 Containment FunctionalStatusSection Functional Status Section 2013‑01‑31
2.16.840.1.113883.10.20.22.1.2 link ContinuityofCareDocumentCCD Continuity of Care Document (CCD) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.8 link DischargeSummary Discharge Summary 2013‑01‑31
2.16.840.1.113883.10.20.22.4.66 Containment FunctionalStatusResultOrganizer Functional Status Result Organizer 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.50 Containment Non-MedicinalSupplyActivity DYNAMIC
2.16.840.1.113883.10.20.22.4.72 Containment CaregiverCharacteristics DYNAMIC
2.16.840.1.113883.10.20.22.4.69 Containment AssessmentScaleObservation DYNAMIC
Item DT Card Conf Description Label
cda:observation
(FunctionalStatusResultObservation)
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:13889) such that it conf‑13889
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.67
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:13907). conf‑13907
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:13908). conf‑13908
  Schematron assert role red error
  test count(cda:code)=1
  Message SHALL contain exactly one [1..1] code (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:13908).
treetree cda:text
0 .. 1 R SHOULD contain zero or one [0..1] text (CONF:13926). conf‑13926
treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:13927).

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‑13927
  Schematron assert role red error
  test count(cda:text/cda:reference[@value])=0 or starts-with(cda:text/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:13929). conf‑13929
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
1 .. 1 M SHALL contain exactly one [1..1] effectiveTime (CONF:13930). conf‑13930
treetree cda:value
1 .. 1 M SHALL contain exactly one [1..1] value (CONF:13932).

If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96)
conf‑13932
  Schematron assert role red error
  test not(cda:value/@xsi:type='CD') or (cda:value/@xsi:type='CD' and count(cda:value[@codeSystem='2.16.840.1.113883.6.96'])=1)
  Message If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96)
treetree cda:interpretationCode
0 .. * R SHOULD contain zero or more [0..*] interpretationCode (CONF:13933). conf‑13933
treetree cda:methodCode
0 .. 1 MAY contain zero or one [0..1] methodCode (CONF:13934). conf‑13934
treetree cda:targetSiteCode
0 .. 1 MAY contain zero or one [0..1] targetSiteCode (CONF:13935). conf‑13935
treetree cda:author
0 .. 1 MAY contain zero or one [0..1] author (CONF:13936). conf‑13936
treetree cda:entryRelationship
where
[cda:supply [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.50']]
0 .. 1 conf‑13892
treeblank treetree @typeCode
1 .. 1 F REFR
  Contains 2.16.840.1.113883.10.20.22.4.50 Non-Medicinal Supply Activity (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.72']]
0 .. 1 conf‑13895
treeblank treetree @typeCode
1 .. 1 F REFR
  Contains 2.16.840.1.113883.10.20.22.4.72 Caregiver Characteristics (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.69']]
0 .. 1 conf‑14465
treeblank treetree @typeCode
1 .. 1 F COMP
  Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (DYNAMIC)
treetree cda:referenceRange
0 .. * R SHOULD contain zero or more [0..*] referenceRange (CONF:13937). conf‑13937
treeblank treetree cda:observationRange
1 .. 1 M The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:13938).

This observationRange SHALL NOT contain [0..0] code
conf‑13938
  Schematron assert role red error
  test not(cda:referenceRange/cda:observationRange/cda:code)
  Message This observationRange SHALL NOT contain [0..0] code