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

Resource Profile: PriorLevelOfCognitiveFunction

Defining URL:http://hl7.org/fhir/us/pacio-cs/StructureDefinition/pacio-plcf
Version:0.1.0
Name:PriorLevelOfCognitiveFunction
Title:PACIO Prior Level of Cognitive Function
Status:Active as of 2020-10-19T22:42:17+00:00
Definition:

An exchange of prior level of cognitive function data for a patient. (The use of this profile is encouraged in the absence of formal prior level of cognitive assessments.)

Publisher:HL7 Patient Care Work Group
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/us/pacio-cs/StructureDefinition/pacio-plcf

Formal Views of Profile Content

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

This structure is derived from USCoreLaboratoryResultObservationProfile

Summary

Mandatory: 3 elements
Must-Support: 2 elements

Extensions

This structure refers to these extensions:

This structure is derived from USCoreLaboratoryResultObservationProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*USCoreLaboratoryResultObservationProfileMeasurements and simple assertions
... text 1..1NarrativeText summary of the prior level of cognitive function for the patient.
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(Location)Where event occurred
URL: http://hl7.org/fhir/StructureDefinition/event-location
... code 1..1CodeableConceptLaboratory Test Name
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11332-4
..... display1..1stringRepresentation defined by the system
Fixed Value: History of Cognitive Function Narrative
.... text 0..1stringPlain text representation of the concept
Required Pattern: History of Cognitive Function Narrative
... effective[x] 1..1dateTime, PeriodClinically relevant time/time-period for observation
... performer 1..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)The person who performed the assessment. May also be used to provide the practitioner role and organization.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*USCoreLaboratoryResultObservationProfileMeasurements and simple assertions
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 1..1NarrativeText summary of the prior level of cognitive function for the patient.
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(Location)Where event occurred
URL: http://hl7.org/fhir/StructureDefinition/event-location
... assistance-required S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category S1..*(Slice Definition)Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred)
.... category:Laboratory S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred)

Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptLaboratory Test Name
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11332-4
..... display1..1stringRepresentation defined by the system
Fixed Value: History of Cognitive Function Narrative
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
Required Pattern: History of Cognitive Function Narrative
... subject SΣ1..1Reference(US Core Patient Profile)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣI1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer Σ1..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)The person who performed the assessment. May also be used to provide the practitioner role and organization.
... value[x] SΣI0..1Result Value
us-core-4: SHOULD use Snomed CT for coded Results
us-core-3: SHALL use UCUM for coded quantity units.
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason SI0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible)
... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example)
... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred)
.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*See referenceRangeProvides guide for interpretation of component result

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*USCoreLaboratoryResultObservationProfileMeasurements and simple assertions
... event-location 0..1Reference(Location)Where event occurred
URL: http://hl7.org/fhir/StructureDefinition/event-location
... assistance-required 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
... status ?!Σ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
.... category:Laboratory 1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred)

Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
... code Σ1..1CodeableConceptLaboratory Test Name
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11332-4
..... display1..1stringRepresentation defined by the system
Fixed Value: History of Cognitive Function Narrative
... subject Σ1..1Reference(US Core Patient Profile)Who and/or what the observation is about
... effective[x] ΣI1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... value[x] ΣI0..1Result Value
us-core-4: SHOULD use Snomed CT for coded Results
us-core-3: SHALL use UCUM for coded quantity units.
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason I0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible)

doco Documentation for this format

This structure is derived from USCoreLaboratoryResultObservationProfile

Summary

Mandatory: 3 elements
Must-Support: 2 elements

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from USCoreLaboratoryResultObservationProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*USCoreLaboratoryResultObservationProfileMeasurements and simple assertions
... text 1..1NarrativeText summary of the prior level of cognitive function for the patient.
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(Location)Where event occurred
URL: http://hl7.org/fhir/StructureDefinition/event-location
... code 1..1CodeableConceptLaboratory Test Name
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11332-4
..... display1..1stringRepresentation defined by the system
Fixed Value: History of Cognitive Function Narrative
.... text 0..1stringPlain text representation of the concept
Required Pattern: History of Cognitive Function Narrative
... effective[x] 1..1dateTime, PeriodClinically relevant time/time-period for observation
... performer 1..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)The person who performed the assessment. May also be used to provide the practitioner role and organization.

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation I0..*USCoreLaboratoryResultObservationProfileMeasurements and simple assertions
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 1..1NarrativeText summary of the prior level of cognitive function for the patient.
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(Location)Where event occurred
URL: http://hl7.org/fhir/StructureDefinition/event-location
... assistance-required S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/pacio-cs/StructureDefinition/assistance-required
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!SΣ1..1coderegistered | preliminary | final | amended +
Binding: ObservationStatus (required)
... category S1..*(Slice Definition)Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred)
.... category:Laboratory S1..1CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred)

Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: laboratory
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptLaboratory Test Name
Binding: LOINCCodes (required)
Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 11332-4
..... display1..1stringRepresentation defined by the system
Fixed Value: History of Cognitive Function Narrative
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
Required Pattern: History of Cognitive Function Narrative
... subject SΣ1..1Reference(US Core Patient Profile)Who and/or what the observation is about
... focus Σ0..*Reference(Resource)What the observation is about, when it is not about the subject of record
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣI1..1Clinically relevant time/time-period for observation
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDate/Time this version was made available
... performer Σ1..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)The person who performed the assessment. May also be used to provide the practitioner role and organization.
... value[x] SΣI0..1Result Value
us-core-4: SHOULD use Snomed CT for coded Results
us-core-3: SHALL use UCUM for coded quantity units.
.... valueQuantityQuantity
.... valueCodeableConceptCodeableConcept
.... valueStringstring
.... valueBooleanboolean
.... valueIntegerinteger
.... valueRangeRange
.... valueRatioRatio
.... valueSampledDataSampledData
.... valueTimetime
.... valueDateTimedateTime
.... valuePeriodPeriod
... dataAbsentReason SI0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible)
... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example)
... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example)
... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange I0..*BackboneElementProvides guide for interpretation
obs-3: Must have at least a low or a high or text
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low I0..1SimpleQuantityLow Range, if relevant
.... high I0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred)
.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example)
.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example)
.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason I0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible)
.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible)
.... referenceRange 0..*See referenceRangeProvides guide for interpretation of component result

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet / Code
Observation.languagepreferredCommonLanguages
Max Binding: AllLanguages
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.category:LaboratorypreferredPattern: laboratory
Observation.coderequiredPattern: LOINC code 11332-4("History of Cognitive Function Narrative")
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Constraints

IdPathDetailsRequirements
us-core-4Observation.value[x]SHOULD use Snomed CT for coded Results
: valueCodeableConcept.coding.system.empty() or valueCodeableConcept.coding.system = 'http://snomed.info/sct'
us-core-3Observation.value[x]SHALL use UCUM for coded quantity units.
: valueQuantity.system.empty() or valueQuantity.system = 'http://unitsofmeasure.org'
obs-3Observation.referenceRangeMust have at least a low or a high or text
: low.exists() or high.exists() or text.exists()