WE Care Assessment

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 4/6/2023
  • SDWG: Approved: 4/6/2023

C-CDA 2.1 Example:

  • Social History Section 2.16.840.1.113883.10.20.22.2.17:2015-08-01
  • Assessment Scale Observation 2.16.840.1.113883.10.20.22.4.69:2022-06-01
  • Assessment Scale Supporting Observation 2.16.840.1.113883.10.20.22.4.86:2015-08-01

Reference to full CDA sample:

  • None

Validation location

Comments

  • WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) is a clinic-based screening and referral system developed for pediatric settings USCF.
  • This example includes the assessment in the Social History section

Custodian

  • Brett Marquard brett@waveoneassociates.com (GitHub: brettmarquard)

Keywords

  • Social History, Smoking

 

Example: download example view on GitHub 

<section>
	<!-- An assessment should be included in the section where it is appropriate in clinical context -->
	<!-- Other asssessments may go into other sections. Depression screening is clinically appropriate for Mental Status -->
	<templateId root="2.16.840.1.113883.10.20.22.2.17"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.17" extension="2015-08-01"/>
	<code code="29762-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
		displayName="Social History"/>
	<title>Social History</title>
	<text>
		<table>
			<thead>
				<tr>
					<th>Date</th>
					<th>Assessment</th>
					<th>Value</th>
				</tr>
			</thead>
			<tbody>
				<!-- Note that WE Care doesn't include total score, detailed responses shown below -->
				<tr>
					<td ID="assessment" colspan="5">WE Care Survey</td>
				</tr>
				<!-- WE CARE Questions -->
				<tr ID="assessment1">
					<td>06/22/2015</td>
					<td>WE CARE Question: Do you have a high school degree?</td>
					<td>No</td>
				</tr>
				<tr ID="assessment2">
					<td>06/22/2015</td>
					<td>WE CARE Question: If no, would you like help to get a GED?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment3">
					<td>06/22/2015</td>
					<td>WE CARE Question: Do you have a job?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment4">
					<td>06/22/2015</td>
					<td>WE CARE Question: If no, would you like help with finding employment and or
						job training?</td>
					<td>Maybe Later</td>
				</tr>
				<!-- How do we code no answer. FHIR NLM LHC Omits -->
				<tr ID="assessment5">
					<td>06/22/2015</td>
					<td>WE CARE Question: Do you need daycare for your child?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment6">
					<td>06/22/2015</td>
					<td>WE CARE Question: If yes, would you like help finding it?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment7">
					<td>06/22/2015</td>
					<td>WE CARE Question: Do you think you are at risk of becoming homeless?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment8">
					<td>06/22/2015</td>
					<td>WE CARE Question: If yes, would you like help with this?</td>
					<td>No</td>
				</tr>
				<tr ID="assessment9">
					<td>06/22/2015</td>
					<td>WE CARE Question: If yes, is this an emergency?</td>
					<td>No</td>
				</tr>
				<tr ID="assessment10">
					<td>06/22/2015</td>
					<td>WE CARE Question: Do you always have enough food for your family?</td>
					<td>No</td>
				</tr>
				<tr ID="assessment11">
					<td>06/22/2015</td>
					<td>WE CARE Question: If no, would you like help with this?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment12">
					<td>06/22/2015</td>
					<td>WE CARE Question: If yes, do you need food for tonight?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment13">
					<td>06/22/2015</td>
					<td>WE CARE Question: Do you have trouble paying your heating bill and or
						electricity bill?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment14">
					<td>06/22/2015</td>
					<td>WE CARE Question: If yes, would you like help with this?</td>
					<td>Yes</td>
				</tr>
				<tr ID="assessment15">
					<td>06/22/2015</td>
					<td>WE CARE Question: If yes, are you at risk of having your utilities shut off
						in the next week?</td>
					<td>No</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<observation classCode="OBS" moodCode="EVN">
			<!-- Assessment Scale Observation -->
			<templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
			<id root="48a7c8f7-30d6-4173-b3c4-4ad4abcfdb1a"/>
			<code code="96447-8" displayName="WE CARE Survey" codeSystem="2.16.840.1.113883.6.1"
				codeSystemName="LOINC"/>
			<text>
				<reference value="#assessment"/>
			</text>
			<statusCode code="completed"/>
			<effectiveTime value="20150622"/>
			<!-- Note that the value attribute is required in an assessment scale observation. Since LOINC organizes this information -->
			<!-- Where the total score is part of the panel, that total score code is shown through entryRelationship to supporting observation -->
			<!-- The WE CARE scale does NOT have a total score so a numeric INT is inappropriate -->
			<value xsi:type="CD" nullFlavor="NA"/>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<!-- Assessment Scale Supporting Observation -->
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="a6a704ab-271a-4bfa-9f0d-1581da2b1235"/>
					<code code="96446-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment1"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA32-8" displayName="No"
						codeSystem="2.16.840.1.113883.6.1"/>

				</observation>
			</entryRelationship>
			<!-- The total score may be adequate for some use cases, although detail components can be sent as shown below as warranted by use case -->
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="a6a704ab-271a-4bfa-9f0d-1581da2b1186"/>
					<code code="96445-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment2"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="466f43c8-fc2b-4161-b9a1-2d88688e5f74"/>
					<code code="96444-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment3"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="e3e5b3d7-76f5-48f1-8ba0-b2b4e6314f95"/>
					<code code="96443-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment4"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA31439-5" displayName="Maybe Later"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="4d77eb67-6588-4f77-b506-1d987eee1711"/>
					<code code="96442-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment5"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="b24d5a2c-48d6-46a0-bd92-1c901e577cc3"/>
					<code code="96433-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment6"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="c67c51ea-4928-449d-b6c0-0f85b1975e07"/>
					<code code="96441-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment7"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="68301d32-9158-429b-92b6-1f1e553a2f8c"/>
					<code code="96440-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment8"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA32-8" displayName="No"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="400a66ad-3d5f-4b6e-913e-81e46241d83b"/>
					<code code="96439-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment9"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA32-8" displayName="No"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="36792a59-7905-406e-a920-701a2ae746be"/>
					<code code="96434-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment10"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA32-8" displayName="No"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="36792a59-7905-406e-a920-701a2ae746be"/>
					<code code="96438-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment11"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="36792a59-7905-406e-a920-701a2ae746be"/>
					<code code="96437-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment12"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="36792a59-7905-406e-a920-701a2ae746be"/>
					<code code="96436-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment13"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="36792a59-7905-406e-a920-701a2ae746be"/>
					<code code="96753-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment14"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA33-6" displayName="Yes"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
			<entryRelationship typeCode="COMP">
				<observation classCode="OBS" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2015-08-01"/>
					<id root="36792a59-7905-406e-a920-701a2ae746be"/>
					<code code="96435-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
					<text>
						<reference value="#assessment15"/>
					</text>
					<statusCode code="completed"/>
					<effectiveTime value="20150622"/>
					<!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
					<value xsi:type="CO" code="LA32-8" displayName="No"
						codeSystem="2.16.840.1.113883.6.1"/>
				</observation>
			</entryRelationship>
		</observation>
	</entry>
</section>

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