Draft| Description |
This clinical statement represents details of an evaluation or assessment of a patient's functional status. The evaluation may include assessment of a patient's language, vision, hearing, activities of daily living, behavior, general function, mobility, and self-care status. The statement, if present, will include supporting caregivers, non-medical devices, and the time period for which the evaluation and assessment were performed |
| Used by 2 transactions and 4 templates, Uses 3 templates | ||||||||||||||||||||||||||||||||||||||||||||
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Discharge Summary (Release 1.1)
| Item | DT | Card | Conf | Description | Label |
|---|---|---|---|---|---|
| cda:observation | Func tion | ||||
| @classCode | cs | 1 … 1 | F | OBS | conf3905 |
| @moodCode | cs | 1 … 1 | F | EVN | conf3906 |
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:13889) such that it | conf3889 |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.67 | conf3890 |
| cda:id | II | 1 … * | SHALL contain at least one [1..*] id (CONF:13907). | conf3907 | |
| cda:code | CD | 1 … 1 | M | SHALL contain exactly one [1..1] code (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:13908). | conf3908 |
| @codeSystem | CONF | 1 … 1 | F | 2.16.840.1.113883.6.1 | |
| cda:text | 0 … 1 | R | SHOULD contain zero or one [0..1] text (CONF:13926). | conf3926 | |
| cda:reference | 0 … 1 | R | The text, if present, SHOULD contain zero or one [0..1] reference (CONF:13927).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) | conf3927 | |
| Schematron assert | role |  error | |||
| test | not(@value) or starts-with(@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) | ||||
| cda:statusCode | CS | 1 … 1 | M | SHALL contain exactly one [1..1] statusCode (CONF:13929). | conf3929 |
| @code | CONF | 1 … 1 | F | completed | |
| cda:effectiveTime | IVL_TS | 1 … 1 | SHALL contain exactly one [1..1] effectiveTime (CONF:13930). | conf3930 | |
| cda:value | 1 … 1 | SHALL contain exactly one [1..1] value (CONF:13932).If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) | conf3932 | ||
| Schematron assert | role | error | |||
| test | not(@xsi:type='CD') or @codeSystem='2.16.840.1.113883.6.96' | ||||
| Message | If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) | ||||
| cda:interpretationCode | 0 … * | R | SHOULD contain zero or more [0..*] interpretationCode (CONF:13933). | conf3933 | |
| cda:methodCode | 0 … 1 | MAY contain zero or one [0..1] methodCode (CONF:13934). | conf3934 | ||
| cda:targetSiteCode | 0 … 1 | MAY contain zero or one [0..1] targetSiteCode (CONF:13935). | conf3935 | ||
| cda:author | 0 … 1 | MAY contain zero or one [0..1] author (CONF:13936). | conf3936 | ||
| cda:entryRelationship | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.4.50 Non-Medicinal Supply Activity (2013‑01‑31) | conf3892 | ||
| @typeCode | cs | 1 … 1 | F | REFR | conf4596 |
| cda:entryRelationship | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.4.72 Caregiver Characteristics (2013‑01‑31) | conf3895 | ||
| @typeCode | cs | 1 … 1 | F | REFR | conf4597 |
| cda:entryRelationship | 0 … 1 | Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (2013‑01‑31) | conf4465 | ||
| @typeCode | cs | 1 … 1 | F | COMP | conf4598 |
| cda:referenceRange | 0 … * | R | SHOULD contain zero or more [0..*] referenceRange (CONF:13937). | conf3937 | |
| cda:observationRange | 1 … 1 | M | The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:13938).This observationRange SHALL NOT contain [0..0] code | conf3938 | |
| cda:code | CD | NP | This observationRange SHALL NOT contain [0..0] code | conf3938 | |