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pending Template  Functional Status Problem Observation

Template 2.16.840.1.113883.10.20.22.4.68 - FunctionalStatusProblemObservation
Id 2.16.840.1.113883.10.20.22.4.68
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 2.16.840.1.113883.10.20.22.4.68
Open/Closed Open (other than defined elements are allowed)
Description A functional status problem observation is a clinical statement that represents a patient’s functional performance and ability.
Used by / Uses
Used by / Uses 6 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
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
(FunctionalStatusProblemObservation)
treetree @classCode
1 .. 1 F OBS
treetree @moodCode
1 .. 1 F EVN
treetree @negationInd
0 .. 1  
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:14312) such that it conf‑14312
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.68
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:14284). conf‑14284
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:14314). conf‑14314
treeblank treetree @code
1 .. 1 F 248536006
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.96 (SNOMED CT)
treetree cda:text
0 .. 1 R SHOULD contain zero or one [0..1] text (CONF:14304). conf‑14304
treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15552).

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‑15552
treeblank treeblank treetree @value
0 .. 1  
  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:14286). conf‑14286
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
0 .. 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:14287). conf‑14287
treeblank treetree cda:low
1 .. 1 M The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:26456). conf‑33564
treeblank treetree cda:high
0 .. 1 The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:26457). conf‑33565
treetree cda:value
CD 1 .. 1 SHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHOULD be selected from ValueSet Problem 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:14291).

If the diagnosis is unknown or the SNOMED code is unknown, @nullFlavor SHOULD be “UNK”. If the code is something other than SNOMED, @nullFlavor SHOULD be “OTH” and the other code SHOULD be placed in the translation element.
conf‑14291
treeblank treetree @nullFlavor
0 .. 1  
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.7.4 Problem (DYNAMIC)
treetree cda:methodCode
0 .. 1 MAY contain zero or one [0..1] methodCode (CONF:14316). conf‑14316
treetree cda:entryRelationship
where
[cda:supply [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.50']]
0 .. * conf‑14294
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 .. * conf‑14298
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 .. * conf‑14463
treeblank treetree @typeCode
1 .. 1 F COMP
  Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (DYNAMIC)