No Cognitive Impairment(C-CDAR2.1).xml

<section>
    <!-- This is an example of how to affirmatively assert there is no mental status impairment -->
    <!-- Note that in C-CDA 1.1, functional and cognitive status (mental) are within the same section -->
    <!-- If no information is known (i.e. assessment not performed), then a pattern of null entries would be more appropriate -->
    <!-- This example uses terminology to assert 'No Impairment' rather than 'Impairment' and negationInd='true' (as value.negationInd) since template design didn't include guidance on negation. --> 
    <!-- The test data also included the No Impairment code. -->
    <!-- Section not backwards compaitble with prior 2.16.840.1.113883.10.20.22.2.14 since new section --> 
    <templateId root="2.16.840.1.113883.10.20.22.2.56" extension="2015-08-01" />
    <code code="10190-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Mental status Narrative" />
    <title>MENTAL STATUS</title>    
    <!-- Narrative organized as a single table. Some systems may prefer separate tables for functional vs. cognitive assessments -->
    <text>
        <table>
            <thead>
                <tr>
                    <th>Assessment</th>
                    <th>Date</th>
                    <th>Results</th>
                    <th>Comments</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="MS_Narrative1">
                    <td ID="MS_Type1">Cognitive Status</td> 
                    <td>August 15 2012, 5:32pm</td>
                    <td ID="MS_Finding1">No impairment</td>
                    <td />
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <!-- Template for Mental Status Observation. Note other templates may apply. -->
        <!-- We chose to use terminology to state 'no impairment' over negation since the C-CDA Mental Status template design didn't include guidance on negation-->
        <observation classCode="OBS" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.74"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.74" extension="2015-08-01"/>
            <id root="faa09c19-fa1f-4a6c-ae79-10a3b711550f"/>
            <code codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" code="373930000" displayName="Cognitive function finding">
                <originalText>
                    <reference value="#MS_Type1" />
                </originalText>
                <translation code="75275-8" 
                    displayName="Cognitive function [Interpretation]"
                    codeSystem="2.16.840.1.113883.6.1"
                    codeSystemName="LOINC"/>
            </code>
            <text>
                <reference value="#MS_Narrative1"/>
            </text>
            <statusCode code="completed"/>
            <effectiveTime>
                <low value="20120815173215-0500"/>
            </effectiveTime>
            <value xsi:type="CD" code="66557003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Disability evaluation, normal, no disability, no impairment">
                <originalText>
                    <reference value="#MS_Finding1"/>
                </originalText>
            </value>
        </observation>
    </entry>
</section>