No Cognitive Impairment

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Example metadata last updated 2017-09-11 05:11:32.117000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 6/18/2015, 6/15/2017
  • SDWG: 7/9/2015
  • SDWG C-CDA R2.1 Upgrade: 7/6/2017

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Comments:

  • This is an example of no cognitive impairment. It only illustrates one potential templated within the mental status section and was originally prepared for the ONC 2014 170.314(b)(2) Transitions of care - M) Functional and Cognitive Status. Note that there are significant changes to functional and cognitive status in C-CDA 2.1 (including section breakout and deprecation of certain templates). This example represents the proper way to send no cognitive impairment in C-CDA R2.1.

Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard) and John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Full sample: Mental Status in empty CCD

Example: download example view on GitHub

<section>
    <!-- This is an example of how to affirmatively assert there is no mental status impairment -->
    <!-- Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section -->
    <!-- If no information is known (i.e. assessment not performed), then a pattern of null entries would be more appropriate -->
    <!-- This example uses terminology to assert 'No Impairment' rather than 'Impairment' and negationInd='true' (as value.negationInd) since template design didn't include guidance on negation. --> 
    <!-- The test data also included the No Impairment code. -->
    <!-- Section not backwards compaitble with prior 2.16.840.1.113883.10.20.22.2.14 since new section --> 
    <templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" />
    <code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="MENTAL STATUS" />
    <title>MENTAL STATUS</title>    
    <!-- Narrative organized as a single table. Some systems may prefer separate tables for functional vs. cognitive assessments -->
    <text>
        <table>
            <thead>
                <tr>
                    <th>Assessment</th>
                    <th>Date</th>
                    <th>Results</th>
                    <th>Comments</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="MS_Narrative1">
                    <td ID="MS_Type1">Cognitive Status</td> 
                    <td>August 15 2012, 5:32pm</td>
                    <td ID="MS_Finding1">No impairment</td>
                    <td></td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <!-- Template for Mental Status Observation. Note other templates may apply. -->
        <!-- We chose to use terminology to state 'no impairment' over negation since the C-CDA Mental Status template design didn't include guidance on negation-->
        <observation classCode="OBS" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.74"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.74" extension="2015-08-01"/>
            <id root="faa09c19-fa1f-4a6c-ae79-10a3b711550f"/>
            <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="373930000" displayName="Cognitive function finding">
                <originalText>
                    <reference value="#MS_Type1"></reference>
                </originalText>
                <translation code="75275-8" 
                    displayName="Cognitive function"
                    codeSystem="2.16.840.1.113883.6.1"
                    codeSystemName="LOINC"/>
            </code>
            <text>
                <reference value="#MS_Narrative1"/>
            </text>
            <statusCode code="completed"/>
            <effectiveTime>
                <low value="20120815173215+0500"/>
            </effectiveTime>
            <value xsi:type="CD" code="66557003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="No Impairment">
                <originalText>
                    <reference value="#MS_Finding1"/>
                </originalText>
            </value>
        </observation>
    </entry>
</section>
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