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  1. CDA Specification Feedback
  2. CDA-20172

Use of Assessment Scale Observation

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    • Icon: Change Request Change Request
    • Resolution: Persuasive with Modification
    • Icon: Highest Highest
    • C-CDA R2.1 Companion Guide (CDA)
    • 3.1.0-ballot [deprecated]
    • Structured Documents
    • (many)
    • 6.2.1.1
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      Will add the following text to the template description:

      An assessment scale is a collection of observations that together can yield a calculated or non-calculated summary evaluation of a one or more conditions. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), Glasgow Coma Scale (assesses coma and impaired consciousness), and WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education - a clinic-based screening and referral system developed for pediatric settings).

      Additionally, will create/reference several examples within the SDOH Assessment guidance area in Volume 1 that will either be linked via the Companion Guide or published in their entirety within the IG (TBD based on discussion with community at publication):

      1) Glasgow Coma (includes total score)

      2) WE CARE (has no total score)

      3) PHQ-9

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      Will add the following text to the template description: An assessment scale is a collection of observations that together can yield a calculated or non-calculated summary evaluation of a one or more conditions. Examples include the Braden Scale (assesses pressure ulcer risk), APACHE Score (estimates mortality in critically ill patients), Mini-Mental Status Exam (assesses cognitive function), APGAR Score (assesses the health of a newborn), Glasgow Coma Scale (assesses coma and impaired consciousness), and WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education - a clinic-based screening and referral system developed for pediatric settings). Additionally, will create/reference several examples within the SDOH Assessment guidance area in Volume 1 that will either be linked via the Companion Guide or published in their entirety within the IG (TBD based on discussion with community at publication): 1) Glasgow Coma (includes total score) 2) WE CARE (has no total score) 3) PHQ-9
    • R Ott/L Nelson: 19-0-0
    • Enhancement
    • Non-substantive

    Description

      In other contexts (assessments of functioning), we have been hesitant to use the Assessment Scale Observation (V2) 2.16.840.1.113883.10.20.22.4.69:2022-06-01 and its contained Assessment Scale Supporting Observation 2.16.840.1.113883.10.20.22.4.86 for panels that are not actually "scales". That is, on these assessments, the independent questions are not used to form an overall (or subscale) score. Many SDOH-related assessments are similar to these functioning assessments in that they do not have scores, totals, or variables that carry the overall impression. Additionally, they don't necessarily fit this template's tidy definition of "a collection of observations that together yield a summary evaluation of a particular condition." In fact, they may span many multitudes of conditions. Further, some of the individual observations/items might well yield their own clinical/social implications (as well as being taken together in a broader screening/assessment context). Consider PRAPARE, for example.

      It would be helpful to clarify whether/how the Assessment Scale Observation structure should be used for assessments that a) don't have total/summary variables, and b) assessments that span multiple conditions and/or have multiple subscales.

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            GDolin Gay Dolin
            dvreeman Daniel Vreeman
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              Updated:
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