1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4: Difference between revisions

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{{CDA Section|NURSING ASSESSMENTS|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|Draft|The assessment section contains all nursing patient assessments. Assessments may be narrative. If specific assessments of pain or level of consciousness are included, they should appear in the respective sub-section. Pain and level of consciousness may also contain entries.    only the required and optional subsections performed.
{{CDA Section|Assessments|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|Trial|The assessments section contains narrative assessments of the patient status.
|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|ParentName=Triage Note
|LOINC=X-ASSESS|LOINCName=ASSESSMENTS
|Code={{CDA Section Code|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|NURSING ASSESSMENTS|R|XASSES-X}}
|Entry|Nursing Assessments Battery|O|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4|}}
|Subsections=
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|Pain Scale|O|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9|Pain Scale must be a subsection of the assessments section and may not stand alone.}}
{{CDA Section Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|Level of Consciousness|O|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10|Level of consciousness must be a subsection of the assessments section and may not stand alone.}}
}}

Latest revision as of 15:11, 1 April 2008

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 https://www.ihe.net/resources/technical_frameworks/#pcc

Assessments Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
General Description The assessments section contains narrative assessments of the patient status.
LOINC Code Opt Description
X-ASSESS R ASSESSMENTS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4 O Nursing Assessments Battery



Sample Assessments Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
    <id root=' ' extension=' '/>
    <code code='X-ASSESS' displayName='ASSESSMENTS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Optional Nursing Assessments Battery element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The Assessments can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "X-ASSESS"]'> 
     Error: The section type code of a Assessments must be X-ASSESS 
   </assert> 
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> 
     Error: The section type code must come from the LOINC code  
     system (2.16.840.1.113883.6.1). 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This Assessments Section does not contain a(n) Nursing Assessments Battery Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the Assessments Section


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