Id2.16.840.1.113883.10.20.22.4.69Effective Date2015‑08‑13
Statusdraft DraftVersion Label2.1
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 6 transactions and 21 templates, Uses 1 template
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
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal 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
2.16.840.1.113883.3.51.60.2.4linkpending BC CDA ClinicalDocumentDischargeSummary (V3) (2.1)2019‑03‑19 14:15:51
2.16.840.1.113883.3.1937.99.61.30.10.54Containmentcancelled Health Concern Act (harmonized) (0.1)2020‑10‑08 10:55:41
2.16.840.1.113883.3.1937.99.61.67.10.24Containmentcancelled XeH Alert Act2021‑04‑20 10:00:04
2.16.840.1.113883.3.1937.99.61.67.10.25Containmentcancelled XeH Risk Concern Act2021‑04‑20 10:06:56
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4linkdraft 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
2.16.840.1.113883.10.20.22.1.13linkdraft 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
2.16.840.1.113883.10.20.22.2.14Containmentdraft Functional Status Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.14Containmentpending Functional Status Section (V2) (2.1)2019‑03‑16 20:25:20
2.16.840.1.113883.10.20.22.2.56Containmentdraft Mental Status Section (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.58linkdraft Health Concerns Section (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.66linkdraft Functional Status Organizer (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.67Containmentdraft Functional Status Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.74Containmentdraft Mental Status Observation (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.75linkdraft Mental Status Organizer (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.127Containmentdraft Sensory Status (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.132Containmentdraft Health Concern Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.136Containmentdraft Risk Concern Act (V2) (2.1)2015‑08‑01
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.86Containmentdraft Assessment Scale Supporting Observation (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
cda:observation
Assedotstion
@classCode
cs1 … 1FOBSCONFdots4434
 SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-14434).
@moodCode
cs1 … 1FEVNCONFdots4435
 SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-14435).
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:81-14436) such that itCONFdots4436
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.69CONFdots4437
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.69" (CONF:81-14437).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:81-14438).CONFdots4438
cda:code
CD1 … 1SHALL contain exactly one [1..1] code (CONF:81-14439).CONFdots4439
cda:derivationExpr
0 … 1MAY contain zero or one [0..1] derivationExpr (CONF:81-14637).

Such derivation expression can contain a text calculation of how the components total up to the summed score 		CONFdots4637
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:81-14444).CONFdots4444
@code
CONF1 … 1Fcompleted
cda:effectiveTime
IVL_TS1 … 1SHALL contain exactly one [1..1] effectiveTime (CONF:81-14445).

Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards) 		CONFdots4445
cda:value
1 … 1RSHALL contain exactly one [1..1] value (CONF:81-14450).CONFdots4450
cda:interpretationCode
0 … *MAY contain zero or more [0..*] interpretationCode (CONF:81-14459).CONFdots4459
cda:translation
0 … *The interpretationCode, if present, MAY contain zero or more [0..*] translation (CONF:81-14888).CONFdots4888
cda:author
0 … *MAY contain zero or more [0..*] author (CONF:81-14460).CONFdots4460
cda:entryRelationship
0 … *RContains 2.16.840.1.113883.10.20.22.4.86 Assessment Scale Supporting Observation (2015‑08‑13)CONFdots4451
@typeCode
cs1 … 1FCOMPCONFdots6741
 SHALL contain exactly one [1..1] @typeCode="COMP" has component (CONF:81-16741).
cda:referenceRange
0 … *MAY contain zero or more [0..*] referenceRange (CONF:81-16799).

The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) 		CONFdots6799
cda:observationRange
1 … 1MThe referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:81-16800).CONFdots6800
cda:text
0 … 1RThis observationRange SHOULD contain zero or one [0..1] text (CONF:81-16801).

The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain) 		CONFdots6801
cda:reference
0 … 1RThe text, if present, SHOULD contain zero or one [0..1] reference (CONF:81-16802).CONFdots6802
@value
0 … 1 The reference, if present, MAY contain zero or one [0..1] @value (CONF:81-16803).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)