Id2.16.840.1.113883.10.20.22.4.69Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameAssessmentScaleObservationDisplay NameAssessment Scale Observation
Description
An assessment scale is a collection of observations that together yield a summary evaluation of a particular condition. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), and Glasgow Coma Scale (assesses coma and impaired consciousness.)
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.69
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 2 transactions and 9 templates, Uses 1 template
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.3Transactionfinal Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.14Containmentdraft Functional Status Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.66linkdraft Functional Status Result Organizer (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.67Containmentdraft Functional Status Result Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.68Containmentdraft Functional Status Problem Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.73Containmentdraft Cognitive Status Problem Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.74Containmentdraft Cognitive Status Result Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.75linkdraft Cognitive Status Result Organizer (1.1)2013‑01‑31
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.86Containmentdraft Assessment Scale Supporting Observation (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:observation
Assedotstion
@classCode
cs1 … 1FOBSconfdots4434
@moodCode
cs1 … 1FEVNconfdots4435
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:14436) such that itconfdots4436
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.69confdots4437
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:14438).confdots4438
cda:code
CD1 … 1SHALL contain exactly one [1..1] code (CONF:14439).confdots4439
cda:derivationExpr
0 … 1MAY contain zero or one [0..1] derivationExpr (CONF:14637).confdots4637
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:14444).confdots4444
@code
CONF1 … 1Fcompleted
cda:effectiveTime
IVL_TS1 … 1SHALL contain exactly one [1..1] effectiveTime (CONF:14445).confdots4445
cda:value
1 … 1RSHALL contain exactly one [1..1] value (CONF:14450).confdots4450
cda:interpretationCode
0 … *MAY contain zero or more [0..*] interpretationCode (CONF:14459).confdots4459
cda:translation
0 … *The interpretationCode, if present, MAY contain zero or more [0..*] translation (CONF:14888).confdots4888
cda:author
0 … *MAY contain zero or more [0..*] author (CONF:14460).confdots4460
cda:entryRelationship
0 … *RContains 2.16.840.1.113883.10.20.22.4.86 Assessment Scale Supporting Observation (2013‑01‑31)confdots4451
@typeCode
cs1 … 1FCOMPconfdots6741
cda:referenceRange
0 … *MAY contain zero or more [0..*] referenceRange (CONF:16799).confdots6799
cda:observationRange
1 … 1MThe referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:16800).confdots6800
cda:text
0 … 1RThis observationRange SHOULD contain zero or one [0..1] text (CONF:16801).confdots6801
cda:reference
0 … 1RThe text, if present, SHOULD contain zero or one [0..1] reference (CONF:16802).

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) 		confdots6802
@value
0 … 1 confdots6803
 Schematron assertrolered error 
 testnot(@value) or starts-with(@value, '#') 
 MessageThis 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)