Id2.16.840.1.113883.10.20.22.4.74Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameMentalStatusObservationV3Display NameMental Status Observation (V3)
Description
The Mental Status Observation template represents an observation about mental status that can come from a broad range of subjective and objective information (including measured data) to address those categories described in the Mental Status Section. See also Assessment Scale Observation for specific collections of observations that together yield a summary evaluation of a particular condition.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.74
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 5 transactions and 13 templates, Uses 2 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal 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
2.16.840.1.113883.3.1937.99.61.30.10.54Containmentcancelled 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
2.16.840.1.113883.10.20.22.1.13linkdraft 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
2.16.840.1.113883.10.20.22.2.56Containmentdraft 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
2.16.840.1.113883.10.20.22.4.75Containmentdraft Mental Status Organizer (V3) (2.1)2015‑08‑01
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
2.16.840.1.113883.10.20.22.4.69Containmentdraft Assessment Scale Observation (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.74 Cognitive Status Result Observation (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:observation
MentdotsonV3
@classCode
cs1 … 1FOBSCONFdots4249
 SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-14249).
@moodCode
cs1 … 1FEVNCONFdots4250
 SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1198-14250).
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.74
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-14255) such that itCONFdots4255
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.74CONFdots4256
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.74" (CONF:1198-14256).
@extension
st1 … 1F2015-08-01CONFdots2565
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32565).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1198-14257).CONFdots4257
cda:code
CD1 … 1MSHALL contain exactly one [1..1] code (CONF:1198-14591).CONFdots4591
@code
CONF1 … 1F373930000
@codeSystem
1 … 1F2.16.840.1.113883.6.96
cda:translation
1 … 1MThis code SHALL contain exactly one [1..1] translation (CONF:1198-32790) such that itCONFdots2790
@code
1 … 1F75275-8CONFdots2791
 SHALL contain exactly one [1..1] @code="75275-8" Cognitive Function (CONF:1198-32791).
@codeSystem
0 … 1F2.16.840.1.113883.6.1CONFdots2792
 SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1 STATIC) (CONF:1198-32792)
@code
CONF1 … 1F75275-8
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:1198-14254).CONFdots4254
@code
CONF1 … 1Fcompleted
cda:effectiveTime
IVL_TS1 … 1SHALL contain exactly one [1..1] effectiveTime (CONF:1198-14261).CONFdots4261
cda:value
1 … 1MSHALL contain exactly one [1..1] value (CONF:1198-14263).CONFdots4263
 Schematron assertrolered error 
 testnot(@xsi:type='CD') or @codeSystem='2.16.840.1.113883.6.96' 
 MessageIf xsi:type=“CD”, *SHOULD* contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) 
cda:author
0 … *RSHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1198-14266).
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)		CONFdots4266
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.69 Assessment Scale Observation (2015‑08‑13)CONFdots4469
@typeCode
cs1 … 1FCOMPCONFdots4595
 SHALL contain exactly one [1..1] @typeCode="COMP" has component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1198-14595).
cda:referenceRange
0 … *MAY contain zero or more [0..*] referenceRange (CONF:1198-14267).

The referenceRange could be used to represent normal or expected capability for the mental function being evaluated.		CONFdots4267