1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2: Difference between revisions

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{{CDA Document|Nursing Note|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2|Comment|
{{CDA Document|Nursing Note|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2|Comment|
Fill this in|
Fill this in|
Index={{T|Data Element|A|B|Rows=
Index={{T|Data Element|A|LOINC|Rows=
{{R|Chief Complaint||}}
{{R|History of Present Illness||}}
{{R|Acuity||}}
{{R|Acuity||}}
{{R|Vital Signs||}}
{{R|Vital Signs||}}
{{R|Pain Scale Assessment||}}
{{R|Interventions||}}
{{R|Assessment||}}
{{R|Assessment||}}
}}
}}
|Data=
|Data=
{{CDA Document Content||Chief Complaint|R||}}
{{CDA Document Content||Acuity|O||If necessary, record the patient's level of conciousness}}
{{CDA Document Content||History of Present Illness|R||}}
{{CDA Document Content||Vital Signs|O||}}
{{CDA Document Content||Acuity|R||}}
{{CDA Document Content||Pain Scale Assessment|O|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1|}}
{{CDA Document Content||Vital Signs|R||}}
{{CDA Document Content||Interventions|R||Record the interventions performed}}
{{CDA Document Content||Assessment|R||}}
{{CDA Document Content||Assessment|R||Record any assessments of the patient condition}}
}}
}}

Revision as of 16:57, 23 May 2007

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

Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2

Fill this in



Data Element Index
Data Element A LOINC
Acuity
Vital Signs
Pain Scale Assessment
Interventions
Assessment

Transition to new CDA Document template to support schematron-->>Data<<--

Specification
Data Element Name Opt Template ID
Acuity
If necessary, record the patient's level of conciousness 		O
Vital Signs O
Pain Scale Assessment O 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Interventions
Record the interventions performed 		R
Assessment
Record any assessments of the patient condition 		R


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 Nursing Note Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Nursing Note</title>
  <effectiveTime value='20260407012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
       
  </structuredBody></component>
</ClinicalDocument>

  

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Nursing Note must be {{{LOINC}}}
   </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>
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