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: CognitiveStatus

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

An exchange of cognitive status data for a patient.

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-cs

Formal Views of Profile Content

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

This structure is derived from USCoreLaboratoryResultObservationProfile

Summary

Mandatory: 2 elements
Must-Support: 1 element

Extensions

This structure refers to these extensions:

This structure is derived from USCoreLaboratoryResultObservationProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*USCoreLaboratoryResultObservationProfileMeasurements and simple assertions
... 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
... basedOn 0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Currently not used in CognitiveStatus.
... status 1..1codeShould have the value 'final' to indicate the observation is complete.
... code 1..1CodeableConceptFor a Post-Acute Care Assessment, should include a LOINC code and text for the question.
Binding: LOINCCodes (extensible)
... subject 1..1Reference(US Core Patient Profile)Should only reference a Patient resource
... focus 0..*Reference(Resource)Currently not used in CognitiveStatus.
... effective[x] 1..1dateTimeClinically relevant time/time-period for observation
... issued 0..1instantCurrently not used in CognitiveStatus.
... 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.
... value[x] 0..1CodeableConceptResult Value
... interpretation 0..*CodeableConceptCurrently not used in CognitiveStatus.
... bodySite 0..1CodeableConceptCurrently not used in CognitiveStatus.
... method 0..1CodeableConceptCurrently not used in CognitiveStatus.
... specimen 0..1Reference(Specimen)Currently not used in CognitiveStatus.
... device 0..1Reference(Device | DeviceMetric)Currently not used in CognitiveStatus.
... referenceRange 0..*BackboneElementCurrently not used in CognitiveStatus.
... hasMember 0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Currently not used in CognitiveStatus.
... component 0..*BackboneElementIf used, the answers for the associated questions (for the purpose of grouping answers under a heading and displaying side-by-side columns)
.... code 1..1CodeableConceptIf used, the LOINC code or text of the column header (for the purpose of grouping answers under a heading and displaying side-by-side columns).
Binding: LOINCCodes (extensible)
.... value[x] 0..1CodeableConceptThe code and text for the answer to the (associated) question.

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 0..1NarrativeText summary of the resource, for human interpretation
... 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
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Currently not used in CognitiveStatus.
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Currently not used in CognitiveStatus.
... status ?!SΣ1..1codeShould have the value 'final' to indicate the observation is complete.
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..1CodeableConceptFor a Post-Acute Care Assessment, should include a LOINC code and text for the question.
Binding: LOINCCodes (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)Should only reference a Patient resource
... focus Σ0..*Reference(Resource)Currently not used in CognitiveStatus.
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣI1..1dateTimeClinically relevant time/time-period for observation
... issued Σ0..1instantCurrently not used in CognitiveStatus.
... 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..1CodeableConceptResult Value
... dataAbsentReason SI0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible)
... interpretation 0..*CodeableConceptCurrently not used in CognitiveStatus.
Binding: ObservationInterpretationCodes (extensible)
... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptCurrently not used in CognitiveStatus.
Binding: SNOMEDCTBodyStructures (example)
... method 0..1CodeableConceptCurrently not used in CognitiveStatus.
Binding: ObservationMethods (example)
... specimen 0..1Reference(Specimen)Currently not used in CognitiveStatus.
... device 0..1Reference(Device | DeviceMetric)Currently not used in CognitiveStatus.
... referenceRange I0..*BackboneElementCurrently not used in CognitiveStatus.
.... 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)Currently not used in CognitiveStatus.
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementIf used, the answers for the associated questions (for the purpose of grouping answers under a heading and displaying side-by-side columns)
.... 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..1CodeableConceptIf used, the LOINC code or text of the column header (for the purpose of grouping answers under a heading and displaying side-by-side columns).
Binding: LOINCCodes (extensible)
.... value[x] Σ0..1CodeableConceptThe code and text for the answer to the (associated) question.
.... 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
... status ?!Σ1..1codeShould have the value 'final' to indicate the observation is complete.
Binding: ObservationStatus (required)
... category 1..*(Slice Definition)Classification of type of observation
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred)
.... 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
... subject Σ1..1Reference(US Core Patient Profile)Should only reference a Patient resource
... effective[x] ΣI1..1dateTimeClinically relevant time/time-period for observation
... value[x] ΣI0..1CodeableConceptResult Value
... dataAbsentReason I0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible)

doco Documentation for this format

This structure is derived from USCoreLaboratoryResultObservationProfile

Summary

Mandatory: 2 elements
Must-Support: 1 element

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from USCoreLaboratoryResultObservationProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*USCoreLaboratoryResultObservationProfileMeasurements and simple assertions
... 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
... basedOn 0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Currently not used in CognitiveStatus.
... status 1..1codeShould have the value 'final' to indicate the observation is complete.
... code 1..1CodeableConceptFor a Post-Acute Care Assessment, should include a LOINC code and text for the question.
Binding: LOINCCodes (extensible)
... subject 1..1Reference(US Core Patient Profile)Should only reference a Patient resource
... focus 0..*Reference(Resource)Currently not used in CognitiveStatus.
... effective[x] 1..1dateTimeClinically relevant time/time-period for observation
... issued 0..1instantCurrently not used in CognitiveStatus.
... 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.
... value[x] 0..1CodeableConceptResult Value
... interpretation 0..*CodeableConceptCurrently not used in CognitiveStatus.
... bodySite 0..1CodeableConceptCurrently not used in CognitiveStatus.
... method 0..1CodeableConceptCurrently not used in CognitiveStatus.
... specimen 0..1Reference(Specimen)Currently not used in CognitiveStatus.
... device 0..1Reference(Device | DeviceMetric)Currently not used in CognitiveStatus.
... referenceRange 0..*BackboneElementCurrently not used in CognitiveStatus.
... hasMember 0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Currently not used in CognitiveStatus.
... component 0..*BackboneElementIf used, the answers for the associated questions (for the purpose of grouping answers under a heading and displaying side-by-side columns)
.... code 1..1CodeableConceptIf used, the LOINC code or text of the column header (for the purpose of grouping answers under a heading and displaying side-by-side columns).
Binding: LOINCCodes (extensible)
.... value[x] 0..1CodeableConceptThe code and text for the answer to the (associated) question.

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 0..1NarrativeText summary of the resource, for human interpretation
... 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
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Currently not used in CognitiveStatus.
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Currently not used in CognitiveStatus.
... status ?!SΣ1..1codeShould have the value 'final' to indicate the observation is complete.
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..1CodeableConceptFor a Post-Acute Care Assessment, should include a LOINC code and text for the question.
Binding: LOINCCodes (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)Should only reference a Patient resource
... focus Σ0..*Reference(Resource)Currently not used in CognitiveStatus.
... encounter Σ0..1Reference(Encounter)Healthcare event during which this observation is made
... effective[x] SΣI1..1dateTimeClinically relevant time/time-period for observation
... issued Σ0..1instantCurrently not used in CognitiveStatus.
... 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..1CodeableConceptResult Value
... dataAbsentReason SI0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible)
... interpretation 0..*CodeableConceptCurrently not used in CognitiveStatus.
Binding: ObservationInterpretationCodes (extensible)
... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptCurrently not used in CognitiveStatus.
Binding: SNOMEDCTBodyStructures (example)
... method 0..1CodeableConceptCurrently not used in CognitiveStatus.
Binding: ObservationMethods (example)
... specimen 0..1Reference(Specimen)Currently not used in CognitiveStatus.
... device 0..1Reference(Device | DeviceMetric)Currently not used in CognitiveStatus.
... referenceRange I0..*BackboneElementCurrently not used in CognitiveStatus.
.... 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)Currently not used in CognitiveStatus.
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementIf used, the answers for the associated questions (for the purpose of grouping answers under a heading and displaying side-by-side columns)
.... 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..1CodeableConceptIf used, the LOINC code or text of the column header (for the purpose of grouping answers under a heading and displaying side-by-side columns).
Binding: LOINCCodes (extensible)
.... value[x] Σ0..1CodeableConceptThe code and text for the answer to the (associated) question.
.... 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.codeextensibleLOINCCodes
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeextensibleLOINCCodes
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes