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pending Template  Cognitive Status Problem Observation

Template 2.16.840.1.113883.10.20.22.4.73 - CognitiveStatusProblemObservation
Id 2.16.840.1.113883.10.20.22.4.73
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 2.16.840.1.113883.10.20.22.4.73
Open/Closed Open (other than defined elements are allowed)
Description A cognitive status problem observation is a clinical statement that describes a patient's cognitive condition, findings, or symptoms. Examples of cognitive problem observations are inability to recall, amnesia, dementia, and aggressive behavior. A cognitive problem observation is a finding or medical condition. This is different from a cognitive result observation, which is a response to a question that provides insight into the patient's cognitive status, judgment, comprehension ability, or response speed.
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
(CognitiveStatusProblemObservation)
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:14346) such that it conf‑14346
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.73
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:14321). conf‑14321
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:14804). conf‑14804
treeblank treetree @code
1 .. 1 F 373930000
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:14341). conf‑14341
treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15532).

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‑15532
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 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:14323). conf‑14323
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
0 .. 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:14324). conf‑14324
treeblank treetree cda:low
1 .. 1 M The effectiveTime, if present, SHALL contain exactly one [1..1] low (CONF:26458). conf‑33573
treeblank treetree cda:high
0 .. 1 The effectiveTime, if present, MAY contain zero or one [0..1] high (CONF:26459). conf‑33574
treetree cda:value
CD 1 .. 1 M 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:14349). conf‑14349
  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 .. * MAY contain zero or more [0..*] methodCode (CONF:14693). conf‑14693
treetree cda:entryRelationship
where
[cda:supply [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.50']]
0 .. * conf‑14331
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‑14335
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‑14467
treeblank treetree @typeCode
1 .. 1 F COMP
  Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (DYNAMIC)