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pending Template  Assessment Scale Observation

Template 2.16.840.1.113883.10.20.22.4.69 - AssessmentScaleObservation
Id 2.16.840.1.113883.10.20.22.4.69
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 2.16.840.1.113883.10.20.22.4.69
Open/Closed Open (other than defined elements are allowed)
Description An assessment scale is a collection of observations that together yield a summary evaluation of a particular condition. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), and Glasgow Coma Scale (assesses coma and impaired consciousness.)
Used by / Uses
Used by / Uses 28 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
2.16.840.1.113883.10.20.22.4.67 Containment FunctionalStatusResultObservation Functional Status Result Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.66 link FunctionalStatusResultOrganizer Functional Status Result Organizer 2013‑01‑31
2.16.840.1.113883.10.20.22.4.68 Containment FunctionalStatusProblemObservation Functional Status Problem Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.73 Containment CognitiveStatusProblemObservation Cognitive Status Problem Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.74 Containment CognitiveStatusResultObservation Cognitive Status Result Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.75 link CognitiveStatusResultOrganizer Cognitive Status Result Organizer 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.86 Containment AssessmentScaleSupportingObservation DYNAMIC
Item DT Card Conf Description Label
cda:observation
(AssessmentScaleObservation)
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:14436) such that it conf‑14436
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.69
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:14438). conf‑14438
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:14439). conf‑14439
treetree cda:derivationExpr
0 .. 1 MAY contain zero or one [0..1] derivationExpr (CONF:14637). conf‑14637
treetree cda:statusCode
1 .. 1 M SHALL contain exactly one [1..1] statusCode (CONF:14444). conf‑14444
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
1 .. 1 M SHALL contain exactly one [1..1] effectiveTime (CONF:14445). conf‑14445
treetree cda:value
1 .. 1 M SHALL contain exactly one [1..1] value (CONF:14450). conf‑14450
treetree cda:interpretationCode
0 .. * MAY contain zero or more [0..*] interpretationCode (CONF:14459). conf‑14459
treeblank treetree cda:translation
0 .. * The interpretationCode, if present, MAY contain zero or more [0..*] translation (CONF:14888). conf‑14888
treetree cda:author
0 .. * MAY contain zero or more [0..*] author (CONF:14460). conf‑14460
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.86']]
0 .. * R conf‑14451
treeblank treetree @typeCode
1 .. 1 F COMP
  Contains 2.16.840.1.113883.10.20.22.4.86 Assessment Scale Supporting Observation (DYNAMIC)
treetree cda:referenceRange
0 .. * MAY contain zero or more [0..*] referenceRange (CONF:16799). conf‑16799
treeblank treetree cda:observationRange
1 .. 1 M The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:16800). conf‑16800
treeblank treeblank treetree cda:text
0 .. 1 R This observationRange SHOULD contain zero or one [0..1] text (CONF:16801). conf‑16801
treeblank treeblank treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:16802).

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‑16802
treeblank treeblank treeblank treeblank treetree @value
0 .. 1  
  Schematron assert role red error
  test count(cda:referenceRange/cda:observationRange/cda:text/cda:reference[@value])=0 or starts-with(cda:referenceRange/cda:observationRange/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)