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draft Template  Pain Score Observation - Empty

Id 2.16.756.5.30.1.1.10.4.117 Effective Date 2018‑09‑04 18:38:44
Status draft Draft Version Label 2018
Name cdachsmcp_entry_PainScoreObservationEmpty Display Name Pain Score Observation - Empty
Description The pain score observation is a Simple Observation that records the patient's assessment of their pain on a scale from 0 to 10.
Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.4.117
Label IHE PCC TF2 Rev.11, 6.3.4.38
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 1 template
Used by as Name Version
2.16.756.5.30.1.1.10.3.74 Containment draft Pain Scale Assessment Section - coded (2018) 2018‑09‑04 18:10:51
2.16.756.5.30.1.1.10.3.57 link draft Functional Status Assessment Section - coded (2018) 2017‑09‑13 16:31:37
2.16.756.5.30.1.1.10.1.11 link draft Social-medical care plan V2 (2018) 2017‑08‑24 18:00:03
Uses as Name Version
2.16.756.5.30.1.1.10.9.14 Include active Narrative Text Reference (2017) DYNAMIC
Relationship Specialization: template 2.16.756.5.30.1.1.10.4.75 (2016‑11‑11)
Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1 (2017‑03‑23 10:04:31)
Specialization: template 1.3.6.1.4.1.19376.1.5.3.1.4.13 (DYNAMIC)
Example
Example
<observation classCode="OBS" moodCode="EVN">
  <templateId root="2.16.756.5.30.1.1.10.4.117"/>  <templateId root="2.16.756.5.30.1.1.10.4.75"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.13"/>  <id root="790458E0-C06E-44E6-B8E2-9EDA6E12CF78"/>  <code code="38208-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Pain severity"/>  <text>
    <reference value="#nopainscore"/>  </text>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NA"/>  <value xsi:type="CO" nullFlavor="NA"/></observation>
Item DT Card Conf Description Label
hl7:observation
 IHE PCC TF2 Rev.11, 6.3.4.38
@classCode
 cs 0 … 1 F OBS
@moodCode
 cs 1 … 1 F EVN
hl7:templateId
 II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.38
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.117
hl7:templateId
 II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.38
@root
 uid 1 … 1 F 2.16.756.5.30.1.1.10.4.75
hl7:templateId
 II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.38
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1
hl7:templateId
 II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.4.38
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.13
hl7:id
 II 1 … 1 M The ID for this item. IHE PCC TF2 Rev.11, 6.3.4.38
@root
 uid 1 … 1 R MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.
@extension
 st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:code
 CD 1 … 1 R IHE PCC TF2 Rev.11, 6.3.4.38
@code
 cs 1 … 1 F 38208-5
@codeSystem
 oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
 st 1 … 1 F LOINC
@displayName
 st 1 … 1 F Pain severity
Included 1 … 1 from 2.16.756.5.30.1.1.10.9.14 Narrative Text Reference (DYNAMIC)
The human-readable text MUST be generated automatically from the structured information of this element. The text element MUST contain the reference to the corresponding text in the human readable part, ONLY.
hl7:text
 ED 1 … 1 M CDA‑CH V2
hl7:reference
 TEL 1 … 1 M The reference to the corresponding text in the human readable part must be specified by reference to content[@ID]: reference[@value='#xxx'] CDA‑CH V2
@value
 1 … 1 R Reference to the narrative part of the section in the format '#xxx', where xxx is the ID of the corresponding element.
  Schematron assert role red error  
  test starts-with(@value,'#')  
  Message The @value attribute content MUST conform to the format '#xxx', where xxx is the ID of the corresponding <content/> element.  
  Variable let Name idvalue  
  Value substring-after(@value,'#')  
  Schematron assert role red error  
  test ancestor::hl7:structuredBody//*[@ID=$idvalue]  
  Message No narrative text found for this reference (no content element within this document has an ID that corresponds to '<value-of select="$idvalue"/>').  
hl7:statusCode
 CS 1 … 1 M

The statusCode shall be set to 'completed' for all observations.

 IHE PCC TF2 Rev.11, 6.3.4.38
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20025 ActStatusCompleted (DYNAMIC)
hl7:effectiveTime
 TS.CH.TZ 0 … 1 C Date or timestamp of the finding (physiologically relevant time of this observation). IHE PCC TF2 Rev.11, 6.3.4.38
@nullFlavor
 cs 1 … 1 F NA
hl7:value
 CO 1 … * R IHE PCC TF2 Rev.11, 6.3.4.38
@nullFlavor
 cs 1 … 1 F NA