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. package_name: hl7.cda.us.ccda derivation: constraint name: AssessmentScaleObservation type: http://hl7.org/cda/stds/core/StructureDefinition/Observation elements: interpretationCode: index: 18 elements: translation: {index: 19} entryRelationship: index: 21 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: 22 elements: typeCode: pattern: {type: Code, value: COMP} index: 23 observation: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Observation', index: 24} 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: 25 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: 26 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: 27 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: 28 derivationExpr: {short: Such derivation expression can contain a text calculation of how the components total up to the summed score, index: 11} value: {short: 'Intended to hold the calculated score, if a calculated score exists in the originating questionaire or scale from the contained Assessment Scale Observations, and the associated answer integer will be at observation.value.translationCode, if present', index: 17} classCode: pattern: {type: Code, value: OBS} index: 4 author: {index: 20} id: {index: 6} code: short: survey constraint: should-translation: {human: SHOULD contain translation, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/AssessmentScaleObservation', severity: warning, expression: translation.exists()} index: 7 elements: code: pattern: {type: Code, value: survey} index: 8 codeSystem: short: Observation Category Codes pattern: {type: String, value: 2.16.840.1.113883.4.642.1.1125} index: 9 translation: binding: {strength: preferred, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1267.13'} index: 10 required: [codeSystem, code] moodCode: pattern: {type: Code, value: EVN} 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: 16} 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} index: 2 extension: pattern: {type: String, value: '2022-06-01'} index: 3 required: [root, extension] extensions: {} statusCode: index: 14 elements: code: pattern: {type: Code, value: completed} index: 15 required: [code] text: short: SHOULD reference the portion of section narrative text corresponding to this entry index: 12 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: 13 package_version: 4.0.0-ballot 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-ballot required: [id, effectiveTime, value, statusCode, templateId]