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pending Template  Assessment Scale Observation

Id 2.16.840.1.113883.10.20.22.4.69
ref
ccda-
 		Effective Date 2015‑08‑13
Status pending Under pre-publication review Version Label 2.1
Name AssessmentScaleObservation Display Name Assessment 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).
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.69
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 5 templates, Uses 1 template
Used by as Name Version
2.16.840.1.113883.10.20.22.2.14 Containment draft Functional Status Section (V2) (2.1) 2019‑03‑16 20:25:20
2.16.840.1.113883.3.51.60.2.4.1 link draft BC CDA ClinicalDocumentDischargeSummary (V3) (2.1) 2019‑03‑19 14:15:51
2.16.840.1.113883.10.20.22.4.127 Containment pending Sensory Status (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.67 Containment pending Functional Status Observation (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.66 link pending Functional Status Organizer (V2) (2.1) 2014‑06‑09
Uses as Name Version
2.16.840.1.113883.10.20.22.4.86 Containment pending Assessment Scale Supporting Observation (2.1) 2015‑08‑13
Relationship Specialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-
Item DT Card Conf Description Label
cda:observation
(Assdotsion)
treetree @classCode
1 … 1 F OBS CONFdots4434
  SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:81-14434).
treetree @moodCode
1 … 1 F EVN CONFdots4435
  SHALL contain exactly one [1..1] @moodCode="EVN" (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:81-14435).
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:81-14436) such that it CONFdots4436
treeblank treetree @root
1 … 1 F 2.16.840.1.113883.10.20.22.4.69 CONFdots4437
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.69" (CONF:81-14437).
treetree cda:id
II 1 … * SHALL contain at least one [1..*] id (CONF:81-14438). CONFdots4438
treetree cda:code
CD 1 … 1 SHALL contain exactly one [1..1] code (CONF:81-14439). CONFdots4439
treetree cda:derivationExpr
0 … 1 MAY 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
treetree cda:statusCode
CS 1 … 1 M SHALL contain exactly one [1..1] statusCode (CONF:81-14444). CONFdots4444
treeblank treetree @code
CONF 1 … 1 F completed
treetree cda:effectiveTime
IVL_TS 1 … 1 SHALL 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
treetree cda:value
1 … 1 R SHALL contain exactly one [1..1] value (CONF:81-14450). CONFdots4450
treetree cda:interpretationCode
0 … * MAY contain zero or more [0..*] interpretationCode (CONF:81-14459). CONFdots4459
treeblank treetree cda:translation
0 … * The interpretationCode, if present, MAY contain zero or more [0..*] translation (CONF:81-14888). CONFdots4888
treetree cda:author
0 … * MAY contain zero or more [0..*] author (CONF:81-14460). CONFdots4460
treetree cda:entryRelationship
0 … * R Contains 2.16.840.1.113883.10.20.22.4.86 Assessment Scale Supporting Observation (2015‑08‑13) CONFdots4451
treeblank where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.86']]]
treeblank treetree @typeCode
1 … 1 F COMP CONFdots6741
  SHALL contain exactly one [1..1] @typeCode="COMP" has component (CONF:81-16741).
treetree 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
treeblank treetree cda:observationRange
1 … 1 M The referenceRange, if present, SHALL contain exactly one [1..1] observationRange (CONF:81-16800). CONFdots6800
treeblank treeblank treetree cda:text
0 … 1 R This 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
treeblank treeblank treeblank treetree cda:reference
0 … 1 R The text, if present, SHOULD contain zero or one [0..1] reference (CONF:81-16802). CONFdots6802
treeblank treeblank treeblank treeblank treetree @value
0 … 1   The reference, if present, MAY contain zero or one [0..1] @value (CONF:81-16803). CONFdots6803
  Schematron assert role red 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)