Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build United States of America

This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Resource Profile: Mental Status Organizer

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.75 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: MentalStatusOrganizer
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.75:2015-08-01

The Mental Status Organizer template may be used to group related Mental Status Observations (e.g., results of mental tests) and associated Assessment Scale Observations into subcategories and/or groupings by time. Subcategories can be things such as Mood and Affect, Behavior, Thought Process, Perception, Cognition, etc.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDAR2.Organizer

NameFlagsCard.TypeDescription & Constraintsdoco
.. Organizer 1..1CDAR2.OrganizerBase for all types and resources
... classCode 1..1codeRequired Pattern: CLUSTER
... moodCode 1..1code
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.75
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CDThe code selected indicates the category that groups the contained mental status observations (e.g., communication, learning and applying knowledge).
.... code C1..1string1198-14698: **SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime C0..1IVL_TSThe effectiveTime is an interval that spans the effectiveTimes of the contained mental status observations. Because all contained mental status observations have a required time stamp, it is not required that this effectiveTime be populated.
1198-32426: The Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
... Slices for component 0..*ElementSlice: Unordered, Open by value:observation
.... component:mentalStatus 1..*Element
..... observation 1..1MentalStatusObservationBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
1198-14698warningOrganizer.code.code**SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
:
1198-32426errorOrganizer.effectiveTimeThe Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. Organizer 1..1CDAR2.OrganizerBase for all types and resources
... classCode 1..1codeBinding: ActClass (required)
Required Pattern: CLUSTER
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.75
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CDThe code selected indicates the category that groups the contained mental status observations (e.g., communication, learning and applying knowledge).
Binding: v3 Code System ActCode (extensible)
.... code C1..1string1198-14698: **SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: completed
... effectiveTime C0..1IVL_TSThe effectiveTime is an interval that spans the effectiveTimes of the contained mental status observations. Because all contained mental status observations have a required time stamp, it is not required that this effectiveTime be populated.
1198-32426: The Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
... Slices for component 0..*ElementSlice: Unordered, Open by value:observation
.... component:All Slices Content/Rules for all slices
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
.... component:mentalStatus 1..*Element
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... observation 1..1MentalStatusObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Organizer.classCoderequiredPattern: CLUSTER
Organizer.moodCoderequiredFixed Value: EVN
Organizer.codeextensibleActCode
Organizer.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
1198-14698warningOrganizer.code.code**SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
:
1198-32426errorOrganizer.effectiveTimeThe Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Organizer 1..1CDAR2.OrganizerBase for all types and resources
... classCode 1..1codeBinding: ActClass (required)
Required Pattern: CLUSTER
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.75
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 1..*II
... code 1..1CDThe code selected indicates the category that groups the contained mental status observations (e.g., communication, learning and applying knowledge).
Binding: v3 Code System ActCode (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code C1..1string1198-14698: **SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime C0..1IVL_TSThe effectiveTime is an interval that spans the effectiveTimes of the contained mental status observations. Because all contained mental status observations have a required time stamp, it is not required that this effectiveTime be populated.
1198-32426: The Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... reference 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... Slices for component 0..*ElementSlice: Unordered, Open by value:observation
.... component:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
.... component:mentalStatus 1..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... observation 1..1MentalStatusObservationBase for all types and resources
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Organizer.classCoderequiredPattern: CLUSTER
Organizer.moodCoderequiredFixed Value: EVN
Organizer.templateId:primary.nullFlavorrequiredNullFlavor
Organizer.codeextensibleActCode
Organizer.code.nullFlavorrequiredNullFlavor
Organizer.statusCoderequiredActStatus
Organizer.statusCode.nullFlavorrequiredNullFlavor
Organizer.subject.typeCoderequiredFixed Value: SBJ
Organizer.subject.contextControlCoderequiredFixed Value: OP
Organizer.subject.awarenessCodeextensibleTargetAwareness
Organizer.informant.typeCoderequiredFixed Value: INF
Organizer.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
1198-14698warningOrganizer.code.code**SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
:
1198-32426errorOrganizer.effectiveTimeThe Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from CDAR2.Organizer

Summary

Mandatory: 12 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Organizer.templateId is sliced based on the values of value:extension, value:root
  • The element Organizer.component is sliced based on the value of value:observation

Differential View

This structure is derived from CDAR2.Organizer

NameFlagsCard.TypeDescription & Constraintsdoco
.. Organizer 1..1CDAR2.OrganizerBase for all types and resources
... classCode 1..1codeRequired Pattern: CLUSTER
... moodCode 1..1code
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.75
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CDThe code selected indicates the category that groups the contained mental status observations (e.g., communication, learning and applying knowledge).
.... code C1..1string1198-14698: **SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
... statusCode 1..1CS
.... code 1..1stringRequired Pattern: completed
... effectiveTime C0..1IVL_TSThe effectiveTime is an interval that spans the effectiveTimes of the contained mental status observations. Because all contained mental status observations have a required time stamp, it is not required that this effectiveTime be populated.
1198-32426: The Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
... Slices for component 0..*ElementSlice: Unordered, Open by value:observation
.... component:mentalStatus 1..*Element
..... observation 1..1MentalStatusObservationBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
1198-14698warningOrganizer.code.code**SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
:
1198-32426errorOrganizer.effectiveTimeThe Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
:

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Organizer 1..1CDAR2.OrganizerBase for all types and resources
... classCode 1..1codeBinding: ActClass (required)
Required Pattern: CLUSTER
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.75
..... extension 1..1stringRequired Pattern: 2015-08-01
... code 1..1CDThe code selected indicates the category that groups the contained mental status observations (e.g., communication, learning and applying knowledge).
Binding: v3 Code System ActCode (extensible)
.... code C1..1string1198-14698: **SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
... statusCode 1..1CSBinding: ActStatus (required)
.... code 1..1stringRequired Pattern: completed
... effectiveTime C0..1IVL_TSThe effectiveTime is an interval that spans the effectiveTimes of the contained mental status observations. Because all contained mental status observations have a required time stamp, it is not required that this effectiveTime be populated.
1198-32426: The Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
... Slices for component 0..*ElementSlice: Unordered, Open by value:observation
.... component:All Slices Content/Rules for all slices
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
.... component:mentalStatus 1..*Element
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... observation 1..1MentalStatusObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Organizer.classCoderequiredPattern: CLUSTER
Organizer.moodCoderequiredFixed Value: EVN
Organizer.codeextensibleActCode
Organizer.statusCoderequiredActStatus

Constraints

IdGradePath(s)DetailsRequirements
1198-14698warningOrganizer.code.code**SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
:
1198-32426errorOrganizer.effectiveTimeThe Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Organizer 1..1CDAR2.OrganizerBase for all types and resources
... classCode 1..1codeBinding: ActClass (required)
Required Pattern: CLUSTER
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:extension, value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.75
..... extension 1..1stringRequired Pattern: 2015-08-01
... id 1..*II
... code 1..1CDThe code selected indicates the category that groups the contained mental status observations (e.g., communication, learning and applying knowledge).
Binding: v3 Code System ActCode (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code C1..1string1198-14698: **SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
.... codeSystem 0..1string
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: completed
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime C0..1IVL_TSThe effectiveTime is an interval that spans the effectiveTimes of the contained mental status observations. Because all contained mental status observations have a required time stamp, it is not required that this effectiveTime be populated.
1198-32426: The Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... reference 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition
... Slices for component 0..*ElementSlice: Unordered, Open by value:observation
.... component:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
.... component:mentalStatus 1..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1codeFixed Value: COMP
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... observation 1..1MentalStatusObservationBase for all types and resources
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Organizer.classCoderequiredPattern: CLUSTER
Organizer.moodCoderequiredFixed Value: EVN
Organizer.templateId:primary.nullFlavorrequiredNullFlavor
Organizer.codeextensibleActCode
Organizer.code.nullFlavorrequiredNullFlavor
Organizer.statusCoderequiredActStatus
Organizer.statusCode.nullFlavorrequiredNullFlavor
Organizer.subject.typeCoderequiredFixed Value: SBJ
Organizer.subject.contextControlCoderequiredFixed Value: OP
Organizer.subject.awarenessCodeextensibleTargetAwareness
Organizer.informant.typeCoderequiredFixed Value: INF
Organizer.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
1198-14698warningOrganizer.code.code**SHOULD** be selected from ICF (codeSystem 2.16.840.1.113883.6.254) *OR* LOINC (codeSystem 2.16.840.1.113883.6.96) (CONF:1198-14698).
:
1198-32426errorOrganizer.effectiveTimeThe Organizer **SHALL** have at least one of *code* or *effectiveTime* (CONF:1198-32426).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from CDAR2.Organizer

Summary

Mandatory: 12 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Organizer.templateId is sliced based on the values of value:extension, value:root
  • The element Organizer.component is sliced based on the value of value:observation

 

Other representations of profile: CSV, Excel, Schematron