Mental Status Section¶

Template ID: 2.16.840.1.113883.10.20.22.2.56 Version: 2015-08-01 (R2.1 | R2.0) Badge: Extended Section

Overview¶

The Mental Status Section (V2) contains observations and evaluations related to a patient's psychological and mental competency. It includes assessments of appearance, attitude, behavior, mood and affect, speech and language, thought process, thought content, perception, cognition, insight, and judgment.

This section is essential for: - Psychiatric and psychological evaluations - Cognitive assessments (memory, orientation, attention) - Documenting mental health conditions - Tracking mental status changes over time - Care planning for patients with cognitive or psychiatric conditions

Mental status can be documented as individual observations or grouped into organizers by category (e.g., Cognition, Mood and Affect, Behavior).

Template Details¶

Identifiers¶

Root: 2.16.840.1.113883.10.20.22.2.56
Extension: 2015-08-01
LOINC Code: 10190-7 (Mental Status)

Conformance Requirements¶

SHALL contain exactly one [1..1] templateId (CONF:1198-28293)
SHALL contain exactly one [1..1] code with code="10190-7" from LOINC (CONF:1198-28295)
SHALL contain exactly one [1..1] title (CONF:1198-28297)
SHALL contain exactly one [1..1] text (narrative block) (CONF:1198-28298)
MAY contain zero or more [0..*] entry with Mental Status Organizer (CONF:1198-28301)
MAY contain zero or more [0..*] entry with Mental Status Observation (CONF:1198-28305)
MAY contain zero or more [0..*] entry with Assessment Scale Observation (CONF:1198-28313)

Cardinality¶

Section: Optional
Organizers: Optional (0..*)
Observations: Optional (0..*)
Either organizers or observations (or both) should be present

Protocol Requirements¶

The section uses two protocols from ccdakit.protocols.mental_status:

MentalStatusObservationProtocol (individual findings)¶

@property
def category(self) -> str:
    """Category: 'Mood and Affect', 'Cognition', 'Behavior', etc."""

@property
def category_code(self) -> Optional[str]:
    """Code for category (ICF or LOINC preferred)"""

@property
def category_code_system(self) -> Optional[str]:
    """Code system: 'ICF', 'LOINC', or 'SNOMED'"""

@property
def value(self) -> str:
    """Observed value/finding (e.g., 'Depressed mood', 'Alert and oriented')"""

@property
def value_code(self) -> Optional[str]:
    """SNOMED CT code for the observed value"""

@property
def observation_date(self) -> date | datetime:
    """Date/time when observation was made"""

@property
def status(self) -> str:
    """Status: 'active', 'inactive', 'completed'"""

@property
def persistent_id(self) -> Optional[PersistentIDProtocol]:
    """Persistent ID across document versions"""

MentalStatusOrganizerProtocol (grouped findings)¶

@property
def category(self) -> str:
    """Category name: 'Cognition', 'Mood and Affect', 'Behavior', etc."""

@property
def category_code(self) -> str:
    """Code for the category (ICF or LOINC preferred)"""

@property
def category_code_system(self) -> str:
    """Code system: 'ICF' or 'LOINC'"""

@property
def observations(self) -> list[MentalStatusObservationProtocol]:
    """List of mental status observations in this category"""

@property
def effective_time_low(self) -> Optional[date | datetime]:
    """Start of time span for observations"""

@property
def effective_time_high(self) -> Optional[date | datetime]:
    """End of time span for observations"""

@property
def persistent_id(self) -> Optional[PersistentIDProtocol]:
    """Persistent ID across document versions"""

Code Example¶

Basic Usage with Individual Observations¶

from datetime import datetime
from ccdakit import MentalStatusSection, CDAVersion

# Define individual mental status observations
observations = [
    {
        "category": "Mood and Affect",
        "value": "Depressed mood",
        "value_code": "366979004",
        "observation_date": datetime(2024, 3, 15, 10, 30),
        "status": "active",
    },
    {
        "category": "Cognition",
        "value": "Alert and oriented x3",
        "value_code": "248234008",
        "observation_date": datetime(2024, 3, 15, 10, 45),
        "status": "completed",
    },
    {
        "category": "Behavior",
        "value": "Cooperative",
        "value_code": "225331004",
        "observation_date": datetime(2024, 3, 15, 11, 0),
        "status": "completed",
    }
]

# Create section
section = MentalStatusSection(
    observations=observations,
    version=CDAVersion.R2_1
)

# Generate XML
xml_element = section.to_element()

Using Organizers to Group Observations¶

# Define mental status organizers
organizers = [
    {
        "category": "Cognition",
        "category_code": "b1",
        "category_code_system": "ICF",
        "observations": [
            {
                "category": "Cognition",
                "value": "Alert",
                "value_code": "248234008",
                "observation_date": datetime(2024, 3, 20, 9, 0),
                "status": "completed",
            },
            {
                "category": "Cognition",
                "value": "Oriented to person, place, and time",
                "value_code": "285854004",
                "observation_date": datetime(2024, 3, 20, 9, 15),
                "status": "completed",
            },
            {
                "category": "Cognition",
                "value": "Memory intact",
                "value_code": "225488001",
                "observation_date": datetime(2024, 3, 20, 9, 30),
                "status": "completed",
            }
        ]
    },
    {
        "category": "Mood and Affect",
        "category_code": "b152",
        "category_code_system": "ICF",
        "observations": [
            {
                "category": "Mood and Affect",
                "value": "Anxious mood",
                "value_code": "48694002",
                "observation_date": datetime(2024, 3, 20, 10, 0),
                "status": "active",
            },
            {
                "category": "Mood and Affect",
                "value": "Flat affect",
                "value_code": "27268008",
                "observation_date": datetime(2024, 3, 20, 10, 15),
                "status": "active",
            }
        ]
    }
]

section = MentalStatusSection(organizers=organizers)

Combined Observations and Organizers¶

# Mix standalone observations with grouped organizers
observations = [
    {
        "category": "General",
        "value": "Well-groomed appearance",
        "observation_date": datetime(2024, 3, 18, 14, 0),
        "status": "completed",
    }
]

organizers = [
    {
        "category": "Cognition",
        "category_code": "b1",
        "category_code_system": "ICF",
        "observations": [
            {
                "category": "Cognition",
                "value": "Alert and oriented",
                "observation_date": datetime(2024, 3, 18, 14, 15),
                "status": "completed",
            }
        ]
    }
]

section = MentalStatusSection(
    observations=observations,
    organizers=organizers
)

Empty Section¶

# Create section with no data
section = MentalStatusSection(
    observations=[],
    organizers=[],
    version=CDAVersion.R2_1
)

# Generates section with narrative: "No mental status observations recorded"

Comprehensive Psychiatric Evaluation¶

organizers = [
    {
        "category": "Appearance",
        "category_code": "b1801",
        "category_code_system": "ICF",
        "observations": [
            {
                "category": "Appearance",
                "value": "Well-groomed",
                "value_code": "248167002",
                "observation_date": datetime(2024, 2, 10, 9, 0),
                "status": "completed",
            }
        ]
    },
    {
        "category": "Mood and Affect",
        "category_code": "b152",
        "category_code_system": "ICF",
        "observations": [
            {
                "category": "Mood and Affect",
                "value": "Depressed mood",
                "value_code": "366979004",
                "observation_date": datetime(2024, 2, 10, 9, 15),
                "status": "active",
            },
            {
                "category": "Mood and Affect",
                "value": "Blunted affect",
                "value_code": "20602000",
                "observation_date": datetime(2024, 2, 10, 9, 20),
                "status": "active",
            }
        ]
    },
    {
        "category": "Thought Process",
        "category_code": "b1601",
        "category_code_system": "ICF",
        "observations": [
            {
                "category": "Thought Process",
                "value": "Linear and goal-directed",
                "value_code": "225482006",
                "observation_date": datetime(2024, 2, 10, 9, 30),
                "status": "completed",
            }
        ]
    },
    {
        "category": "Cognition",
        "category_code": "b1",
        "category_code_system": "ICF",
        "observations": [
            {
                "category": "Cognition",
                "value": "Alert and oriented x4",
                "value_code": "248234008",
                "observation_date": datetime(2024, 2, 10, 9, 45),
                "status": "completed",
            },
            {
                "category": "Cognition",
                "value": "Memory intact",
                "value_code": "225488001",
                "observation_date": datetime(2024, 2, 10, 10, 0),
                "status": "completed",
            }
        ]
    }
]

section = MentalStatusSection(organizers=organizers)

With Custom Protocol Implementation¶

from dataclasses import dataclass
from datetime import datetime
from typing import Optional, List

@dataclass
class MentalStatusObs:
    """Custom observation implementation."""
    category: str
    value: str
    observation_date: datetime
    status: str
    category_code: Optional[str] = None
    category_code_system: Optional[str] = None
    value_code: Optional[str] = None
    persistent_id: Optional[object] = None

@dataclass
class MentalStatusOrg:
    """Custom organizer implementation."""
    category: str
    category_code: str
    category_code_system: str
    observations: List[MentalStatusObs]
    effective_time_low: Optional[datetime] = None
    effective_time_high: Optional[datetime] = None
    persistent_id: Optional[object] = None

# Create organizers
organizers = [
    MentalStatusOrg(
        category="Cognition",
        category_code="b1",
        category_code_system="ICF",
        observations=[
            MentalStatusObs(
                category="Cognition",
                value="Short-term memory impaired",
                value_code="247592009",
                observation_date=datetime(2024, 3, 25, 11, 0),
                status="active",
            )
        ]
    )
]

section = MentalStatusSection(organizers=organizers)

Official Reference¶

For complete specification details, refer to: - C-CDA Online: Mental Status Section (V2) - Local Reference: references/C-CDA_2.1/templates/2.16.840.1.113883.10.20.22.2.56.html

Best Practices¶

1. Organize by Category¶

Group related mental status observations into logical categories:

categories = [
    "Appearance",
    "Behavior",
    "Mood and Affect",
    "Speech and Language",
    "Thought Process",
    "Thought Content",
    "Perception",
    "Cognition",
    "Insight",
    "Judgment"
]

2. Use Standard Code Systems¶

# ICF (International Classification of Functioning) for categories
"category_code_system": "ICF"

# SNOMED CT for observed values
"value_code_system": "SNOMED"

3. Complete Mental Status Exam¶

# Include all key components of MSE
mse_categories = {
    "Appearance": "b1801",           # ICF
    "Behavior": "d7",                # ICF
    "Mood and Affect": "b152",       # ICF
    "Speech": "b3",                  # ICF
    "Thought Process": "b1601",      # ICF
    "Thought Content": "b1602",      # ICF
    "Perception": "b156",            # ICF
    "Cognition": "b1",               # ICF
    "Insight": "b1644",              # ICF
    "Judgment": "b1645",             # ICF
}

4. Cognitive Assessment Components¶

cognition_observations = [
    "Alert and oriented x4",
    "Attention and concentration intact",
    "Short-term memory intact",
    "Long-term memory intact",
    "Calculation ability normal",
    "Abstract reasoning intact",
]

5. Mood and Affect Descriptors¶

mood_values = [
    "Euthymic",
    "Depressed",
    "Anxious",
    "Irritable",
    "Euphoric",
    "Labile",
]

affect_values = [
    "Full range",
    "Congruent",
    "Flat",
    "Blunted",
    "Restricted",
    "Inappropriate",
]

6. Temporal Accuracy¶

# Always include date/time of observation
{
    "observation_date": datetime(2024, 3, 15, 10, 30),
    "status": "completed",  # Or "active" for ongoing conditions
}

7. Status Management¶

# Completed: Point-in-time observation
{"status": "completed"}

# Active: Ongoing mental status issue
{"status": "active"}

# Inactive: Previously observed but no longer present
{"status": "inactive"}

8. Narrative Generation¶

The section automatically generates an HTML table with: - Category (grouped by organizer or observation category) - Finding/Value with unique ID reference - Date of observation - Status (capitalized)

9. Mini-Mental State Exam (MMSE)¶

# Document standardized assessment scores
mmse_organizer = {
    "category": "Cognitive Assessment - MMSE",
    "category_code": "72106-8",  # LOINC code for MMSE
    "category_code_system": "LOINC",
    "observations": [
        {
            "category": "MMSE Total Score",
            "value": "24/30",  # Indicates mild cognitive impairment
            "observation_date": datetime(2024, 3, 15, 10, 0),
            "status": "completed",
        }
    ]
}

10. Clinical Context¶

# Add relevant clinical observations
{
    "category": "Cognition",
    "value": "Mild short-term memory impairment, consistent with early dementia",
    "observation_date": datetime(2024, 3, 20, 11, 0),
    "status": "active",
}

Common Mental Status Codes¶

ICF Category Codes¶

b1 - Mental functions (general)
b152 - Emotional functions (mood and affect)
b156 - Perceptual functions
b1601 - Form of thought (thought process)
b1602 - Content of thought
b164 - Higher-level cognitive functions

LOINC Codes¶

10190-7 - Mental status (section code)
72106-8 - MMSE total score
52491-8 - Brief psychiatric rating scale

Common SNOMED CT Value Codes¶

248234008 - Alert
285854004 - Oriented
366979004 - Depressed mood
48694002 - Anxious mood
27268008 - Flat affect
225488001 - Memory intact
247592009 - Memory impaired

Common Pitfalls¶

Missing Categories: Don't document only cognition; include mood, behavior, etc.
Incomplete Assessment: Document all components of mental status exam
Missing Dates: Always include when observation was made
Vague Descriptions: Use specific, clinical terminology
No Baseline: Document baseline mental status for comparison
Mixing Current and Historical: Keep current mental status separate from history
Static Documentation: Update mental status as patient condition changes
Missing Standardized Assessments: Include MMSE, PHQ-9, or other validated tools
Inconsistent Observations: Use consistent terminology across assessments
Wrong Status: Use "completed" for point-in-time observations, "active" for ongoing conditions