PACIO Cognitive Status Implementation Guide
0.1.0 - STU Ballot

This page is part of the PACIO Cognitive Status Implementation Guide (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

: BCS-SNF-CAM-Admission-1 - XML Representation

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<Observation xmlns="http://hl7.org/fhir">
  <id value="BCS-SNF-CAM-Admission-1"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/pacio-cs/StructureDefinition/pacio-bcs"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative</b></p><h3>Ids</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><h3>Meta</h3><table class="grid"><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>Event Location</b>: </p><p></p><p><b>category</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}">Laboratory</span></p><p><b>code</b>: <span title="Codes: {http://loinc.org 86585-7}">MDS v3.0 - RAI v1.17.2 - Signs and symptoms of delirium (from CAM) [CMS Assessment]</span></p><p><b>subject</b>: <a href="Patient-patientBSJ1.html">Generated Summary: Betsy Smith-Johnson </a></p><p><b>effective</b>: Apr 9, 2020 11:00:00 PM</p><p><b>performer</b>: </p><ul><li><a href="Practitioner-Practitioner-HoneyJones.html">Generated Summary: active; Honey Jones ; gender: female</a></li><li><a href="PractitionerRole-Role-RN.html">Generated Summary: active; <span title="Codes: {http://snomed.info/sct 224535009}">Registered Nurse</span></a></li><li><a href="Organization-Org-02.html">Organization. Generated Summary: name: Happy Nursing Facility</a></li></ul><p><b>dataAbsentReason</b>: <span title="Codes: {http://terminology.hl7.org/CodeSystem/data-absent-reason not-applicable}">Not Applicable</span></p><p><b>hasMember</b>: </p><ul><li><a href="Observation-BCS-SNF-CAM-Admission-1-Ob-Question-1.html">Generated Summary: <span title="Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}">Laboratory</span>; <span title="Codes: {http://loinc.org 54632-5}">Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the resident's baseline?</span>; effective: Apr 9, 2020 11:00:00 PM; <span title="Codes: {http://loinc.org LA32-8}">No</span></a></li><li><a href="Observation-BCS-SNF-CAM-Admission-1-Ob-Question-3.html">Generated Summary: <span title="Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}">Laboratory</span>; <span title="Codes: {http://loinc.org 54628-3}">Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?</span>; effective: Apr 9, 2020 11:00:00 PM; <span title="Codes: {http://loinc.org LA61-7}">Behavior not present</span></a></li><li><a href="Observation-BCS-SNF-CAM-Admission-1-Ob-Question-5.html">Generated Summary: <span title="Codes: {http://terminology.hl7.org/CodeSystem/observation-category laboratory}">Laboratory</span>; <span title="Codes: {http://loinc.org 54629-1}">Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?</span>; effective: Apr 9, 2020 11:00:00 PM; <span title="Codes: {http://loinc.org LA61-7}">Behavior not present</span></a></li></ul><p><b>derivedFrom</b>: <a href="QuestionnaireResponse-QResponse-SNF-CAM-Admission-1.html">Questionnaire Response. Generated Summary: status: completed; authored: Apr 9, 2020 11:00:00 PM</a></p></div>
  </text>
  <extension url="http://hl7.org/fhir/StructureDefinition/event-location">
    <valueReference>
      <reference value="Location/Org-Loc-02"/>
    </valueReference>
  </extension>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
      <code value="laboratory"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="86585-7"/>
      <display
               value="MDS v3.0 - RAI v1.17.2 - Signs and symptoms of delirium (from CAM) [CMS Assessment]"/>
    </coding>
  </code>
  <subject>
    <reference value="Patient/patientBSJ1"/>
  </subject>
  <effectiveDateTime value="2020-04-09T18:00:00-05:00"/>
  <performer>
    <reference value="Practitioner/Practitioner-HoneyJones"/>
  </performer>
  <performer>
    <reference value="PractitionerRole/Role-RN"/>
  </performer>
  <performer>
    <reference value="Organization/Org-02"/>
    <display value="Organization"/>
  </performer>
  <dataAbsentReason>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/>
      <code value="not-applicable"/>
    </coding>
  </dataAbsentReason>
  <hasMember>
    <reference value="Observation/BCS-SNF-CAM-Admission-1-Ob-Question-1"/>
  </hasMember>
  <hasMember>
    <reference value="Observation/BCS-SNF-CAM-Admission-1-Ob-Question-3"/>
  </hasMember>
  <hasMember>
    <reference value="Observation/BCS-SNF-CAM-Admission-1-Ob-Question-5"/>
  </hasMember>
  <derivedFrom>
    <reference value="QuestionnaireResponse/QResponse-SNF-CAM-Admission-1"/>
    <display value="Questionnaire Response"/>
  </derivedFrom>
</Observation>