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Template Health Status Observation (V2) 2014‑06‑09

Id2.16.840.1.113883.10.20.22.4.5
ref
ccda-
Effective Date2014‑06‑09
Statusdraft DraftVersion Label2.1
NameHealthStatusObservationV2Display NameHealth Status Observation (V2)
Description
This template represents information about the overall health status of the patient. To represent the impact of a specific problem or concern related to the patient's expected health outcome use the Prognosis Observation template 2.16.840.1.113883.10.20.22.4.113.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.5
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 8 transactions and 13 templates, Uses 0 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transactionfinal Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transactionfinal Referral Note (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.61.20.10.10Containmentdraft Problem Section (entries required) (V3) (2.1)2015‑11‑03 08:58:40
2.16.840.1.113883.3.1937.99.61.28.10.3linkdraft CDA de Consulta (1)2017‑04‑22 23:20:01
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13linkdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14linkdraft Referral Note (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15linkdraft Care Plan (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.5Containmentdraft Problem Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.5.1Containmentdraft Problem Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.58Containmentdraft Health Concerns Section (V2) (2.1)2015‑08‑01
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.5 Health Status Observation (2013‑01‑31)
ref
ccda-
ItemDTCardConfDescriptionLabel
cda:observation
HealdotsonV2
@classCode
cs1 … 1FOBSCONFdots9057
 SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-9057).
@moodCode
cs1 … 1FEVNCONFdots9072
 SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-9072).
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.5
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1098-16756) such that itCONFdots6756
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.5CONFdots6757
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.5" (CONF:1098-16757).
@extension
st1 … 1F2014-06-09CONFdots2558
 SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32558).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1098-32486).CONFdots2486
cda:code
CD1 … 1MSHALL contain exactly one [1..1] code (CONF:1098-19143).CONFdots9143
@code
CONF1 … 1F11323-3
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:1098-9074).CONFdots9074
@code
CONF1 … 1Fcompleted
cda:value
CD1 … 1MSHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet HealthStatus urn:oid:2.16.840.1.113883.1.11.20.12 DYNAMIC (CONF:1098-9075).CONFdots9075
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.12 HealthStatus (DYNAMIC)

Template Health Status Observation 2013‑01‑31

Id2.16.840.1.113883.10.20.22.4.5
ref
ccda-
Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameHealthStatusObservationDisplay NameHealth Status Observation
DescriptionThe Health Status Observation records information about the current health status of the patient.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.5
ClassificationCDA Entry Level Template
Open/ClosedClosed (only defined elements are allowed)
Used by / Uses
Used by 7 transactions and 32 templates, Uses 0 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transactionfinal Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.3Transactionfinal Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.5Transactionfinal Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transactionfinal Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.6Transactionfinal Operative Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transactionfinal History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.61.41.10.4linkdraft Discharge Summary (1.1)2018‑02‑19 15:30:38
2.16.840.1.113883.10.20.6.1.2.1linkdraft Findings Section (1.1)2016‑12‑15 05:09:17
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.7linkdraft Operative Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2linkdraft Encounters Section (entries optional) (1.1)2016‑10‑09 02:21:23
2.16.840.1.113883.10.20.22.2.5linkdraft Problem Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.5.1linkdraft Problem Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.20linkdraft History of Past Illness Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.22linkdraft Encounters Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.22.1linkdraft Encounters Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.24linkdraft Hospital Discharge Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.28linkdraft Procedure Findings Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.32linkdraft Complications (OpNote) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.34linkdraft Preoperative Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.36linkdraft Postprocedure Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.37linkdraft Complications Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.37linkdraft Complications Section (1.1)2016‑10‑09 02:01:42
2.16.840.1.113883.10.20.22.2.43linkdraft Hospital Admission Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.3linkdraft Problem Concern Act (Condition) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.4Containmentdraft Problem Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.33linkdraft Hospital Discharge Diagnosis (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.34linkdraft Hospital Admission Diagnosis (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.49linkdraft Encounter Activities (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.51linkdraft Postprocedure Diagnosis (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.65linkdraft Preoperative Diagnosis (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.79linkdraft Deceased Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.80linkdraft Encounter Diagnosis (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:observation
Healdotstion
@classCode
cs1 … 1FOBSconf‑9057
@moodCode
cs1 … 1FEVNconf‑9072
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:16756) such that itconfdots6756
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.5confdots6757
cda:code
CD1 … 1MSHALL contain exactly one [1..1] code (CONF:19143).confdots9143
@code
CONF1 … 1F11323-3
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:text
0 … 1RSHOULD contain zero or one [0..1] text (CONF:9270).conf‑9270
cda:reference
0 … 1RThe text, if present, SHOULD contain zero or one [0..1] reference (CONF:15529).

SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)		confdots5529
@value
0 … 1 confdots5530
 Schematron assertrolered error 
 testnot(@value) or starts-with(@value, '#') 
 MessageSHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:9074).conf‑9074
@code
CONF1 … 1Fcompleted
cda:value
CD1 … 1MSHALL contain exactly one [1..1] value with @xsi:type="CD", where the code SHALL be selected from ValueSet HealthStatus 2.16.840.1.113883.1.11.20.12 DYNAMIC (CONF:9075).conf‑9075
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.12 HealthStatus (DYNAMIC)