1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4

From IHE Wiki
Jump to: navigation, search

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Trial.gif ED Physician Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4

The ED Physician note specification includes sections for data commonly reported by the physician as part of an ED encounter. It includes relevant historical information about the patient, pertinent arrival information, vital signs, history and physical examination findings, assessment and plan, interventions including medications, fluids and procedures, diagnosis and disposition.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:edes:2007

Parent Template

This document is an instance of the Medical Document template.

LOINC Code

The LOINC code for this document is 28568-4 ED Visit Note

Data Element Index
Data Element LOINC
Referral Source 11293-8 ED REFERRAL SOURCE
Mode of Arrival 11459-5 TRANSPORT MODE
Chief Complaint 10154-3 CHIEF COMPLAINT
Reason for Visit 29299-6 REASON FOR VISIT
History of Present Illness 10164-2 HISTORY OF PRESENT ILLNESS
Advance Directives 42348-3 ADVANCE DIRECTIVES
Active Problems 11450-4 PROBLEM LIST
Past Medical History 11348-0 HISTORY OF PAST ILLNESS
Current Medications 10160-0 CURRENT MEDICATIONS
Allergies 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS
List of Surgeries 47519-4 History of procedures
Immunizations 11369-6 HISTORY OF IMMUNIZATIONS
Family History 10157-6 HISTORY OF FAMILY MEMBER DISEASES
Social History 29762-2 SOCIAL HISTORY
History of Pregnancies 10162-6 HISTORY OF PREGNANCIES
Pertinent ROS 10187-3 REVIEW OF SYSTEMS
Vital Signs 8716-3 VITAL SIGNS
Physical Examination 29545-1 PHYSICAL EXAMINATION
Assessment and Plan X-AANDP ASSESSMENT AND PLAN
X-ASSESS ASSESSMENT
18776-5 TREATMENT PLAN
Medications Administered 18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered X-IVFLU INTRAVENOUS FLUID ADMINISTERED
Procedures Performed 29544-3 PROCEDURE
Test Results - Lab, ECG, Radiology 30954-2 STUDIES SUMMARY
Consultations 18693-2 ED CONSULTANT PRACTITIONER
Progress Note 18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)
ED Diagnoses 11301-9 ED DIAGNOSIS
Medications at Discharge 10183-2 HOSPITAL DISCHARGE MEDICATIONS
ED Disposition 11302-7 ED DISPOSITION
Specification
Data Element Name Opt Template ID
Referral Source R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
Mode of Arrival R 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Chief Complaint R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Reason for Visit R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
History of Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Advanced Directives R 1.3.6.1.4.1.19376.1.5.3.1.3.34
Active Problems R2 1.3.6.1.4.1.19376.1.5.3.1.3.6
Past Medical History R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
Current Medications R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
List of Surgeries R 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R 1.3.6.1.4.1.19376.1.5.3.1.3.16
History of Pregnancies
This section should contain one entry containing the date (TS) of last menstrual period for women of childbearing age, using LOINC Code 8665-2 DATE LAST MENSTRUAL PERIOD
R2 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Pertinent ROS R2 1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Physical Examination R 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Assessements
This section shall be present when assessments and plans are recorded separately.
C 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Care Plan
This section shall be present when assessments and plans are recorded separately.
C 1.3.6.1.4.1.19376.1.5.3.1.3.31
Assessment and Plan
This section shall be present when assessments and plans are recorded together.
C 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
Medications Administered R2 1.3.6.1.4.1.19376.1.5.3.1.3.21
Intravenous Fluids Administered R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
Procedures Performed R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Test Results Lab, ECG, Radiology R 1.3.6.1.4.1.19376.1.5.3.1.3.27
Consultations R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8
Progress Note R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
ED Diagnoses R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
Medications at Discharge R2 1.3.6.1.4.1.19376.1.5.3.1.3.22
ED Disposition
The ED Disposition shall contain a mode of transport entry describing how the patient departed.
R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample ED Physician Note Document
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'/> <id root=' ' extension=' '/> <code code='28568-4' displayName='ED Visit Note' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>ED Physician Note</title> <effectiveTime value='20190920012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/>  : <component><structuredBody>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3'/> <!-- Required Referral Source Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/> <!-- Required Mode of Arrival Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/> <!-- Required Chief Complaint Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1'/> <!-- Required Reason for Visit Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/> <!-- Required History of Present Illness Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/> <!-- Required Advanced Directives Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <!-- Required if known Active Problems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/> <!-- Required if known Past Medical History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/> <!-- Required Current Medications Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <!-- Required Allergies Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/> <!-- Required List of Surgeries Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/> <!-- Required Immunizations Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/> <!-- Required Family History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/> <!-- Required Social History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/> <!-- Required if known History of Pregnancies Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/> <!-- Required if known Pertinent ROS Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/> <!-- Required Vital Signs Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/> <!-- Required Physical Examination Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/> <!-- Conditional Assessements Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <!-- Conditional Care Plan Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/> <!-- Conditional Assessment and Plan Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/> <!-- Required if known Medications Administered Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'/> <!-- Required if known Intravenous Fluids Administered Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/> <!-- Required Procedures Performed Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/> <!-- Required Test Results Lab, ECG, Radiology Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8'/> <!-- Required Consultations Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'/> <!-- Required Progress Note Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'/> <!-- Required ED Diagnoses Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/> <!-- Required if known Medications at Discharge Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/> <!-- Required ED Disposition Section content --> </section> </component>
    </structuredBody></component> </ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The ED Physician Note can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for ED Physician Note is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "28568-4"]'>
     Error: The document type code of a ED Physician Note must be 28568-4
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Referral Source Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Mode of Arrival Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Reason for Visit Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Advanced Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Pertinent ROS Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert>    
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Intravenous Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Procedures Performed Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Test Results Lab, ECG, Radiology Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Consultations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Progress Note Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) ED Diagnoses Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Medications at Discharge Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 
   </assert> 
   <assert test='((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])
              and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"])
               or (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]))
             and
              not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]))'>
     Error:  A(n) ED Physician Note shall contain either Assessments AND Care
     Plan OR Assessment and Plan. See
     http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
 </rule>
</pattern>