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pending Template  Pressure Ulcer Observation

Template 2.16.840.1.113883.10.20.22.4.70 - PressureUlcerObservation
Id 2.16.840.1.113883.10.20.22.4.70
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 2.16.840.1.113883.10.20.22.4.70
Open/Closed Open (other than defined elements are allowed)
Description The pressure ulcer observation contains details about the pressure ulcer such as the stage of the ulcer, location, and dimensions. If the pressure ulcer is a diagnosis, you may find this on the problem list. An example of how this would appear is in the Problem Section.
Used by / Uses
Used by / Uses 8 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.2.10 Containment PhysicalExamSection Physical Exam Section 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
2.16.840.1.113883.10.20.22.1.9 link ProgressNote Progress Note 2013‑01‑31
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
Item DT Card Conf Description Label
cda:observation
(PressureUlcerObservation)
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:14387) such that it conf‑14387
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.70
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:14389). conf‑14389
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:14759). conf‑14759
treeblank treetree @code
1 .. 1 F ASSERTION
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.4 (Act Code)
treetree cda:text
0 .. 1 R SHOULD contain zero or one [0..1] text (CONF:14391). conf‑14391
treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:14392).

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‑14392
treeblank treeblank treetree @value
1 .. 1 R
  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:14394). conf‑14394
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
1 .. 1 M SHALL contain exactly one [1..1] effectiveTime (CONF:14395). conf‑14395
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 Pressure Ulcer Stage 2.16.840.1.113883.11.20.9.35 STATIC (CONF:14396).

If the stage 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‑14396
treeblank treetree @nullFlavor
0 .. 1  
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.35 Pressure Ulcer Stage (DYNAMIC)
treetree cda:targetSiteCode
0 .. * R SHOULD contain zero or more [0..*] targetSiteCode (CONF:14797). conf‑14797
treeblank treetree @code
1 .. 1 R
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.36 Pressure Point (DYNAMIC)
treeblank treetree cda:qualifier
0 .. 1 R The targetSiteCode, if present, SHOULD contain zero or one [0..1] qualifier (CONF:14799). conf‑14799
treeblank treeblank treetree cda:name
1 .. 1 M The qualifier, if present, SHALL contain exactly one [1..1] name (CONF:14800). conf‑14800
treeblank treeblank treeblank treetree @code
0 .. 1 F 272741003
treeblank treeblank treeblank treetree @code
1 .. 1 F 272741003
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.96 (SNOMED CT)
  Schematron assert role red error
  test not(cda:targetSiteCode/cda:qualifier) or cda:targetSiteCode/cda:qualifier[count(cda:name)=1]
  Message The qualifier, if present, SHALL contain exactly one [1..1] name (CONF:14800).
treeblank treeblank treetree cda:value
1 .. 1 M The qualifier, if present, SHALL contain exactly one [1..1] value (CONF:14802). conf‑14802
treeblank treeblank treeblank treetree @code
0 .. 1  
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.37 TargetSite Qualifiers (DYNAMIC)
  Schematron assert role red error
  test not(cda:targetSiteCode/cda:qualifier) or cda:targetSiteCode/cda:qualifier[count(cda:value)=1]
  Message The qualifier, if present, SHALL contain exactly one [1..1] value (CONF:14802).
treetree cda:entryRelationship
0 .. 1 R SHOULD contain zero or one [0..1] entryRelationship (CONF:14410) such that it conf‑14410
treeblank treetree @typeCode
1 .. 1 F COMP
treeblank treetree cda:observation
1 .. 1 M SHALL contain exactly one [1..1] observation (CONF:14619). conf‑14619
treeblank treeblank treetree @classCode
1 .. 1 F OBS
treeblank treeblank treetree @moodCode
1 .. 1 F EVN
treeblank treeblank treetree cda:code
1 .. 1 M This observation SHALL contain exactly one [1..1] code (CONF:14620). conf‑14620
treeblank treeblank treeblank treetree @code
1 .. 1 F 401238003
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.96 (SNOMED CT)
treeblank treeblank treetree cda:value
PQ 1 .. 1 M This observation SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:14622). conf‑14622
treetree cda:entryRelationship
0 .. 1 R SHOULD contain zero or one [0..1] entryRelationship (CONF:14601) such that it conf‑14601
treeblank treetree @typeCode
1 .. 1 F COMP
treeblank treetree cda:observation
1 .. 1 M SHALL contain exactly one [1..1] observation (CONF:14623). conf‑14623
treeblank treeblank treetree @classCode
1 .. 1 F OBS
treeblank treeblank treetree @moodCode
1 .. 1 F EVN
treeblank treeblank treetree cda:code
1 .. 1 M This observation SHALL contain exactly one [1..1] code (CONF:14624). conf‑14624
treeblank treeblank treeblank treetree @code
1 .. 1 F 401239006
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.96 (SNOMED CT)
treeblank treeblank treetree cda:value
PQ 1 .. 1 M This observation SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:14626). conf‑14626
treetree cda:entryRelationship
0 .. 1 R SHOULD contain zero or one [0..1] entryRelationship (CONF:14605) such that it conf‑14605
treeblank treetree @typeCode
1 .. 1 F COMP
treeblank treetree cda:observation
1 .. 1 M SHALL contain exactly one [1..1] observation (CONF:14627). conf‑14627
treeblank treeblank treetree @classCode
1 .. 1 F OBS
treeblank treeblank treetree @moodCode
1 .. 1 F EVN
treeblank treeblank treetree cda:code
1 .. 1 M This observation SHALL contain exactly one [1..1] code (CONF:14628). conf‑14628
treeblank treeblank treeblank treetree @code
1 .. 1 F 425094009
treeblank treeblank treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.96 (SNOMED CT)
treeblank treeblank treetree cda:value
PQ 1 .. 1 M This observation SHALL contain exactly one [1..1] value with @xsi:type="PQ" (CONF:14630). conf‑14630