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    hl7.cda.us.ccda@4.0.0
    http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation
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).\n\nWhen an Assessment Scale Observation is contained in a Problem Observation, a Social History Observation or a Procedure instance that is Social Determinant of Health focused, that Assessment scale **MAY** contain assessment scale observations that represent question and answer pairs from SDOH screening instruments that are represented in LOINC. Note that guidance on the use of LOINC in assessment scales already exists in Assessment Scale Observation constraints and Assessment Scale Supporting Observations constraints.\n\nThe Observation value is used to record a calculated score using an integer. A LOINC answer concept is used when the assessment is non-calculated result.\n\n#### Templates Used\nAlthough open templates may contain any valid CDA content, the following templates are specifically called out by this template:\n\n**Optional EntryRelationships**: [AssessmentScaleSupportingObservation](StructureDefinition-AssessmentScaleSupportingObservation.html)'
package_name: hl7.cda.us.ccda
derivation: constraint
name: AssessmentScaleObservation
type: http://hl7.org/cda/stds/core/StructureDefinition/Observation
elements:
  interpretationCode:
    index: 20
    elements:
      translation: {index: 21}
  entryRelationship:
    index: 23
    slicing:
      rules: open
      discriminator:
      - {path: observation, type: profile}
      - {path: typeCode, type: value}
      min: null
      slices:
        supportingObs:
          match: {typeCode: COMP}
          schema:
            short: entryRelationship
            array: true
            index: 24
            elements:
              typeCode:
                pattern: {type: code, value: COMP}
                type: code
                index: 25
              observation: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Observation', index: 26}
            required: [observation]
  referenceRange:
    short: 'The referenceRange/observationRange/text, if present, MAY contain a description of the scale (e.g., for a Pain Scale 1 to 10: 1 to 3 = little pain, 4 to 7 = moderate pain, 8 to 10 = severe pain)'
    index: 27
    elements:
      observationRange:
        constraint:
          should-text: {human: SHOULD contain text, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation', severity: warning, expression: text.exists()}
          should-text-ref-value: {human: SHOULD contain text/reference/@value, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation', severity: warning, expression: text.reference.value.exists()}
        index: 28
        elements:
          text:
            short: 'The text may contain a description of the scale (e.g., for a Pain Scale 1 to 10:  1 to 3 = little pain, 4 to 7= moderate pain, 8 to 10 = severe pain)'
            index: 29
            elements:
              reference:
                constraint:
                  value-starts-octothorpe: {human: 'If reference/@value is present, it SHALL begin with a ''#'' and SHALL point to its corresponding narrative', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation', severity: error, expression: value.exists() implies value.startsWith('#')}
                index: 30
  derivationExpr: {short: Such derivation expression can contain a text calculation of how the components total up to the summed score, index: 13}
  value: {short: This is intended to hold the overall assessment score.  This could be calculated from the contained Assessment Scale Supporting Observations, index: 19}
  classCode:
    pattern: {type: code, value: OBS}
    type: code
    index: 4
  author: {index: 22}
  id: {index: 6}
  code:
    short: For Social Determinant of Health Assessments
    binding: {strength: required, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13'}
    constraint:
      should-translation: {human: SHOULD contain translation, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation', severity: warning, expression: translation.exists()}
    index: 11
    elements:
      translation:
        binding: {strength: preferred, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1247.206'}
        index: 12
  moodCode:
    pattern: {type: code, value: EVN}
    type: code
    index: 5
  effectiveTime: {short: 'Represents clinically effective time of the measurement, which may be when the measurement was performed (e.g., a BP measurement), or may be when sample was taken (and measured some time afterwards)', index: 18}
  templateId:
    index: 0
    slicing:
      rules: open
      discriminator:
      - {path: root, type: value}
      - {path: extension, type: value}
      min: 1
      slices:
        assessment-scale-obs:
          match: {root: 2.16.840.1.113883.10.20.22.4.69, extension: '2022-06-01'}
          schema:
            _required: true
            index: 1
            elements:
              root:
                pattern: {type: string, value: 2.16.840.1.113883.10.20.22.4.69}
                type: string
                index: 2
              extension:
                pattern: {type: string, value: '2022-06-01'}
                type: string
                index: 3
            required: [extension, root]
            extensions: {}
  sdtcCategory:
    short: Category is optional, but if present it SHALL contain a category with code=survey.
    index: 7
    slicing:
      rules: open
      discriminator:
      - {path: code, type: value}
      - {path: codeSystem, type: value}
      min: null
      slices:
        survey:
          match: {code: survey, codeSystem: 2.16.840.1.113883.4.642.1.1125}
          schema:
            short: Survey
            index: 8
            elements:
              code:
                pattern: {type: code, value: survey}
                type: code
                index: 9
              codeSystem:
                pattern: {type: string, value: 2.16.840.1.113883.4.642.1.1125}
                type: string
                index: 10
            required: [code, codeSystem]
  statusCode:
    index: 16
    elements:
      code:
        pattern: {type: code, value: completed}
        type: code
        index: 17
    required: [code]
  text:
    short: SHOULD reference the portion of section narrative text corresponding to this entry
    index: 14
    elements:
      reference:
        constraint:
          value-starts-octothorpe: {human: 'If reference/@value is present, it SHALL begin with a ''#'' and SHALL point to its corresponding narrative', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation', severity: error, expression: value.exists() implies value.startsWith('#')}
        index: 15
package_version: 4.0.0
class: logical
kind: logical
url: http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation
base: http://hl7.org/cda/stds/core/StructureDefinition/Observation
version: 4.0.0
required: [effectiveTime, id, statusCode, templateId, value]