Specification - Extended

HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

Document Description

extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

Existing Wording

In the Mental Status Observation (V3) template, the current constraint is: SHALL contain exactly one [1..1] code (CONF:1198-14591). a. This code SHALL contain exactly one [1..1] @code="373930000" Cognitive function (CONF:1198-32788). SHALL contain exactly one [1..1] value (CONF:1198-14263). a. If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271). ----------------------- The constraint is too loose, allowing all possible SNOMED CT codes if the value is a concept descriptor. Therefore it is possible to populate any SNOMED concept which might not be appropriate or in the correct context for assessing cognitive function. (e.g.: nausea, diabetes, amnesia (disorder), etc.).

Proposed Wording

Suggestion: SHALL contain exactly one [1..1] value (CONF:1198-14263). a. If xsi:type=“CD”, SHOULD contain a code from SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:1198-14271) which SHALL be selected from the SNOMED child concepts of code 373930000 cognitive function (finding)