Draft| 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 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 | Cogn tion | ||||
| @classCode | cs | 1 … 1 | F | OBS | conf4249 |
| @moodCode | cs | 1 … 1 | F | EVN | conf4250 |
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:14255) such that it | conf4255 |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.74 | conf4256 |
| cda:id | II | 1 … * | SHALL contain at least one [1..*] id (CONF:14257). | conf4257 | |
| cda:code | CD | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:14591). | conf4591 |
| @code | CONF | 1 … 1 | F | 373930000 | |
| @codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.96 | ||
| cda:text | 0 … 1 | R | SHOULD contain zero or one [0..1] text (CONF:14258). | conf4258 | |
| 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) | conf5549 | |
| @value | 0 … 1 | conf5550 | |||
| 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:14254). | conf4254 |
| @code | CONF | 1 … 1 | F | completed | |
| cda:effectiveTime | IVL_TS | 1 … 1 | SHALL contain exactly one [1..1] effectiveTime (CONF:14261). | conf4261 | |
| 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) | conf4263 | |
| 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:14264). | conf4264 | |
| cda:methodCode | CE | 0 … 1 | MAY contain zero or one [0..1] methodCode (CONF:14265). | conf4265 | |
| cda:targetSiteCode | CD | 0 … 1 | MAY contain zero or one [0..1] targetSiteCode (CONF:14270). | conf4270 | |
| cda:author | 0 … 1 | MAY contain zero or one [0..1] author (CONF:14266). | conf4266 | ||
| cda:entryRelationship | 0 … * | Contains 2.16.840.1.113883.10.20.22.4.50 Non-Medicinal Supply Activity (2013‑01‑31) | conf4272 | ||
| @typeCode | cs | 1 … 1 | F | REFR | conf4593 |
| cda:entryRelationship | 0 … * | Contains 2.16.840.1.113883.10.20.22.4.72 Caregiver Characteristics (2013‑01‑31) | conf4276 | ||
| @typeCode | cs | 1 … 1 | F | REFR | conf4594 |
| cda:entryRelationship | 0 … * | Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (2013‑01‑31) | conf4469 | ||
| @typeCode | cs | 1 … 1 | F | COMP | conf4595 |
| cda:referenceRange | 0 … * | R | SHOULD contain zero or more [0..*] referenceRange (CONF:14267). | conf4267 | |
| cda:observationRange | 1 … 1 | M | The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:14268). | conf4268 | |
| cda:code | CD | NP | This observationRange SHALL NOT contain [0..0] code (CONF:14269). | conf4269 | |