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).

When 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.

The 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.

Templates Used

Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:

Optional EntryRelationships: AssessmentScaleSupportingObservation