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pending Template  Cognitive Status Result Observation

Template 2.16.840.1.113883.10.20.22.4.74 - CognitiveStatusResultObservation
Id 2.16.840.1.113883.10.20.22.4.74
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 2.16.840.1.113883.10.20.22.4.74
Open/Closed Open (other than defined elements are allowed)
Description This clinical statement contains details of an evaluation or assessment of a patient’s cognitive status. The evaluation may include assessment of a patient's mood, memory, and ability to make decisions. The statement, if present, will include supporting caregivers, non-medical devices, and the time period for which the evaluation and assessment were performed. This is different from a cognitive status problem observation, which 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.
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
2.16.840.1.113883.10.20.22.4.75 Containment CognitiveStatusResultOrganizer Cognitive 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
(CognitiveStatusResultObservation)
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:14255) such that it conf‑14255
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.74
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:14257). conf‑14257
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:14591). conf‑14591
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:14258). conf‑14258
treeblank treetree cda:reference
0 .. 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:15549).

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‑15549
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:14254). conf‑14254
treeblank treetree @code
1 .. 1 F completed
treetree cda:effectiveTime
1 .. 1 M SHALL contain exactly one [1..1] effectiveTime (CONF:14261). conf‑14261
treetree cda:value
1 .. 1 M SHALL contain exactly one [1..1] value (CONF:14263).

If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96)
conf‑14263
  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:14264). conf‑14264
treetree cda:methodCode
CE 0 .. 1 MAY contain zero or one [0..1] methodCode (CONF:14265). conf‑14265
treetree cda:targetSiteCode
CD 0 .. 1 MAY contain zero or one [0..1] targetSiteCode (CONF:14270). conf‑14270
treetree cda:author
0 .. 1 MAY contain zero or one [0..1] author (CONF:14266). conf‑14266
treetree cda:entryRelationship
where
[cda:supply [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.50']]
0 .. * conf‑14272
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‑14276
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‑14469
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:14267). conf‑14267
treeblank treetree cda:observationRange
1 .. 1 M The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:14268). conf‑14268
treeblank treeblank treetree cda:code
This observationRange SHALL NOT contain [0..0] code (CONF:14269). conf‑14269
  Schematron assert role red error
  test not(cda:referenceRange/cda:observationRange/cda:code)
  Message This observationRange SHALL NOT contain [0..0] code (CONF:14269).