|
|
| (8 intermediate revisions by 2 users not shown) |
| Line 1: |
Line 1: |
| {{HL7V3|Nursing Assessments Battery|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|draft|This entry describes a single row in the Nursing Assessment flowsheet. The single observation date/time and provider is applied to all other observations. | | {{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. |
| |Example=<br/> | | |LOINC=X-ASSESS|LOINCName=ASSESSMENTS |
| <entry>
| | |Entry|Nursing Assessments Battery|O|1.3.6.1.4.1.19376.1.5.3.1.1.13.3.4|}} |
| <organizer classCode='BATTERY' moodCode='EVN'>
| |
| <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
| |
| <id root=' ' extension=' '/>
| |
| <code code='(XASSES-X)' displayName='Nursing Assessments'
| |
| codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
| |
| <statusCode code='completed'/>
| |
| <author>
| |
| <time value=' '/>
| |
| <assignedAuthor>
| |
| <id root=' ' extension=' '/>
| |
| </assignedAuthor>
| |
| </author>
| |
| <component>
| |
| <observation classCode='OBS' moodCode='EVN'>
| |
| <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
| |
| :
| |
| </observation>
| |
| </component>
| |
| <component>
| |
| <observation classCode='OBS' moodCode='EVN'>
| |
| <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.13'/>
| |
| :
| |
| </observation>
| |
| </component>
| |
| :
| |
| </organizer>
| |
| </entry>
| |
| }}
| |
| | |
| | |
| ===== <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/> =====
| |
| The <templateId> element specifies that this organizer entry conforms to the EDER Nursing Assessments battery. The root attribute SHALL contain the value "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"
| |
| | |
| ===== <organizer classCode='BATTERY' moodCode='EVN'> =====
| |
| Each row in the Nursing Assessments battery be represented by an organizer with the classCode of 'BATTERY' and the moodCode of 'EVN'
| |
| | |
| ===== <id root=' ' extension=' '/> =====
| |
| Each battery SHALL have a globally unique identifier.
| |
| | |
| ===== <code code='(XASSES-X)' codeSystem='2.16.840.1.113883.6.1'/> =====
| |
| The <code> element specifies the Loinc code that represents the content of the battery. The codeSystem attribute SHALL contain the value '2.16.840.1.113883.6.1'. The code attribute SHALL contain the value='(XASSES-X)'. It is good practice to include displayName and codeSystemName for clarity and debugging. The corresponding values are 'Nursing Assessments battery' and 'LOINC' respectively.
| |
| | |
| ===== <author/><time/><assignedAuthor><id/></assignedAuthor></author> =====
| |
| The <author> relation element points at the author that records the visit battery. This assignedAuthor may be different than the author of the document. The time element is used to record when the assigned author recorded the battery.
| |
| | |
| ===== <statusCode code='completed'/> =====
| |
| The status code for all batteries SHALL be 'completed'
| |
| | |
| ===== <component> =====
| |
| The battery is made of several component {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.11.2.3.2|1.3.6.1.4.1.19376.1.5.3.1.4.13|simple observation}}s. The following table lists the allowable LOINC codes, displayNames, and observation types, and unit of measures for these observations.
| |
| | |
| {|border=1
| |
| |-bgcolor='#d9d9d9'
| |
| !code
| |
| !displayName
| |
| !xsi:type
| |
| !units
| |
| !value set
| |
| | |
| |-
| |
| |9269-2
| |
| |GLASGOW COMA SCORE.TOTAL
| |
| |CO
| |
| |N/A
| |
| |3..15
| |
| | |
| |-
| |
| |9268-4
| |
| |GLASGOW COMA SCORE.MOTOR
| |
| |CO
| |
| |N/A
| |
| |1..6
| |
| | |
| |-
| |
| |11454-6
| |
| |LEVEL OF RESPONSIVENESS
| |
| |CO
| |
| |N/A
| |
| |
| |
| ALERT
| |
| | |
| VERBAL RESPONSE
| |
| | |
| PAINFUL RESPONSE
| |
| | |
| UNRESPONSIVE
| |
| | |
| UNKNOWN
| |
| | |
| |-
| |
| |XLOC-X
| |
| |LEVEL OF CONSCIOUSNESS
| |
| |CO
| |
| |N/A
| |
| |
| |
| |-
| |
| |38208-5
| |
| |PAIN SEVERITY
| |
| |CO
| |
| |N/A
| |
| |0-10
| |
| |-
| |
| |48767-8
| |
| |(COMMENT FIELD)
| |
| |ED
| |
| |
| |
| |
| |
| |-
| |
| |}
| |
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
