Memory Impairment

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Example metadata last updated 2017-12-11 19:21:11.779000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 6/15/2017
  • SDWG: 7/6/2017

SITE C-CDA Validator

Comments:

  • This is an example of mental (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 a mental 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 a memory (cognitive) impairment -->
    <!-- Original design influenced by Transitions of Care test scenario, inpatient for MU2 170.314(b)(2)-->
    <!-- Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section -->
    <!-- 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> 
                    <!-- Some systems may just report this to day rather than hour and minute timestamp. Both of which are acceptable. -->
                    <td>August 15 2012, 5:32pm</td>
                    <td ID="MS_Finding1">Memory Impairment</td>
                    <td></td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <!-- Template for Mental Status Result Observation. Note other templates may apply. -->
        <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"/>
            <!-- In C-CDA R2.1 August 2015 this is a fixed code. SDWG may change to a value set in STU comment 1367 -->
            <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>
                <!-- Some systems may just report this to day rather than hour and minute timestamp. Both of which are acceptable. -->
                <low value="20120815173215-0500"/>
            </effectiveTime>
            <value xsi:type="CD" code="386807006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Memory impairment">
                <originalText>
                    <reference value="#MS_Finding1"/>
                </originalText>
            </value>
        </observation>
    </entry>
</section>
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