1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1

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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

Comment.gif Care Plan Specification 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1

The nursing evaluation and management note contains the information relevant to the six components of the nursing process described by the American Nursing Association Standards of Nursing Practice (ANA 2004). These include:

  • Assessment
    The assessment includes nursing assessments, review of systems and/or physical examination details and vital signs as necessary, as well as any necessary assessments of functional status or risks to the patient. Additional sections may be added to include relevant family / social history, or other key knowledge necessary to the implementation of the nursing plan.
  • Nursing Diagnosis
    The problem list section includes any nursing and physician diagnoses that are relevant to or being treated by the care plan.
  • Expected Outcomes
    Identification of the expected outcomes for the patient (the goals).
  • Planning
    Planning describes the treatments and interventions to be implemented to reach the expected outcomes under the plan.
  • Orders
    The care plan must include a section referencing provider orders and actions that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera), monitoring (testing, monitoring, et cetera), education.
  • Implementation
    The procedures and interventions section is used to report the actions performed and care provided to the patient.
  • Evaluation
    The progress notes section is where the evaluation of the effectiveness of the plan towards the goals is documented, and may include assessments of the patient response to the treatment plan.



LOINC Code

The LOINC code for this document is 34746-8 Nursing Evaluation and Management Note

Standards
CDAR2 HL7 CDA Release 2.0
CCD ASTM/HL7 Continuity of Care Document
ANA 2004 ANA Nursing Scope and Standard of Practice
Data Element Index
Data Element LOINC ANA 2004
Assessment X-ASSESS ASSESSMENTS Assessment
  Physical Examination 29545-1 PHYSICAL EXAMINATION Assessment
  Review of Systems 10187-3 REVIEW OF SYSTEMS Assessment
  Functional Status Assessment 47420-5 Functional Status Assessment Assessment
  Family History 10157-6 HISTORY OF FAMILY MEMBER DISEASES Assessment
  Social History 29762-2 SOCIAL HISTORY Assessment
Active Problems 11450-4 PROBLEM LIST Nursing Diagnosis
Allergies 48765-2 Allergies, adverse reactions, alerts
Care Plan 18776-5 Plan of Treatment Planning and Outcome Identification
Provider Orders 46209-3 PROVIDER ORDERS Planning
Advance Directives 42348-3 ADVANCE DIRECTIVES Planning
Procedures and Interventions 29544-3 PROCEDURES Implementation
Medications Administered 18610-6 MEDICATION ADMINISTERED Implementation
Fluids Administered 8975-5 INTRAVASCULAR FLUID INTAKE Implementation
Progress X-PROGRESS Progress Evaluation
History of Past Illness 11348-0 HISTORY OF PAST ILLNESS
Surgical History 47519-4 HISTORY OF PROCEDURES
Specification
Data Element Name Opt Template ID
Assessments
This section shall include all assessments performed.
R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Physical Examination
The physical examination section shall be present when a physical examination is performed during the assessment of the patient.
C 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Review of Systems
The review of systems section shall be present when a review of systems is performed during the assessment of the patient.
C 1.3.6.1.4.1.19376.1.5.3.1.3.18
Functional Status Assessment
This section shall be present when include any assessments of functional status were performed on on the patient.
C 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Family History O 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History O 1.3.6.1.4.1.19376.1.5.3.1.3.16
Active Problems
The problem list section includes any nursing and physician diagnoses that are relevant to or being treated by the care plan.
R 1.3.6.1.4.1.19376.1.5.3.1.3.6
Allergies and Other Adverse Reactions Section
This section shall be present and record the presense or absense of any allergies.
R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Care Plan
The care plan section shall include a subsection documenting the provider orders.
R 1.3.6.1.4.1.19376.1.5.3.1.3.31
Provider Orders
orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera), monitoring (testing, monitoring, et cetera), education and follow-up care.
R 1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1
Advance Directives
This section shall be present and record the presense or absense of any advance directives.
R 1.3.6.1.4.1.19376.1.5.3.1.3.34
Procedures and Interventions
This section shall be present when procedures and interventions are performed.
C 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Medications Administered
This section shall be present when medications have been administered.
C 1.3.6.1.4.1.19376.1.5.3.1.3.21
Fluids Administered
This section shall be present when IV fluids have been administered.
C 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
History of Past Illness Section
This section shall be present when there is relevant history of past illness.
C 1.3.6.1.4.1.19376.1.5.3.1.3.8
Coded List of Surgeries Section
This section shall be present when there is relevant surgical history.
C 1.3.6.1.4.1.19376.1.5.3.1.3.12
Immunizations Section
This section shall be present to record relevant immunization status.
C 1.3.6.1.4.1.19376.1.5.3.1.3.23

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.

Sample Care Plan Document
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1'/>
  <id root=' ' extension=' '/>
  <code code='34746-8' displayName='Nursing Evaluation and Management Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Care Plan</title>
  <effectiveTime value='20200702012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
        <!-- Required Assessments Section content -->
      </section>
    </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/> <!-- Conditional Physical Examination Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/> <!-- Conditional Review of Systems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/> <!-- Conditional Functional Status Assessment Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/> <!-- Optional Family History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/> <!-- Optional Social History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/> <!-- Required Active Problems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <!-- Required Allergies and Other Adverse Reactions Section Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/> <!-- Required Care Plan Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1'/> <!-- Required Provider Orders Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/> <!-- Required Advance Directives Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/> <!-- Conditional Procedures and Interventions Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/> <!-- Conditional 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'/> <!-- Conditional Fluids Administered Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/> <!-- Conditional History of Past Illness Section Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.12'/> <!-- Conditional Coded List of Surgeries Section Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/> <!-- Conditional Immunizations Section Section content --> </section> </component>
    </structuredBody></component> </ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Care Plan can only be used on Clinical Documents.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "34746-8"]'>
     Error: The document type code of a Care Plan must be 34746-8
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) Functional Status Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Document does not contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Document does not contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </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 Care Plan Document must contain a(n) Allergies and Other Adverse Reactions Section Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Provider Orders Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </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 Care Plan Document must contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) Procedures and Interventions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) History of Past Illness Section Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.12"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) Coded List of Surgeries Section Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Care Plan Document does not contain a(n) Immunizations Section Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
 </rule>
</pattern>