1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2: Difference between revisions

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Index={{T|Data Element|A|LOINC|Rows=
Index={{T|Data Element|A|LOINC|Rows=
{{R|Acuity||}}
{{R|Level of Conciousness||}}
{{R|Vital Signs||}}
{{R|Vital Signs||}}
{{R|Pain Scale Assessment||}}
{{R|Pain Scale Assessment||}}
Line 8: Line 8:
{{R|Assessment||}}
{{R|Assessment||}}
}}
}}
|Data=
|Section|Vital Signs|R||
{{CDA Document Content||Acuity|O||If necessary, record the patient's level of conciousness}}
|Section|Level of Conciousness|O||
{{CDA Document Content||Vital Signs|O||}}
|Section|Pain Scale Assessment|O|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1|
{{CDA Document Content||Pain Scale Assessment|O|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1|}}
|Section|Interventions|R||Record the interventions performed
{{CDA Document Content||Interventions|R||Record the interventions performed}}
|Section|Assessment|R||Record any assessments of the patient condition
{{CDA Document Content||Assessment|R||Record any assessments of the patient condition}}
}}
}}

Revision as of 17:04, 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

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Data Element Index
Data Element A LOINC
Level of Conciousness
Vital Signs
Pain Scale Assessment
Interventions
Assessment
Specification
Data Element Name Opt Template ID
Vital Signs R
Level of Conciousness 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>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/>
        <!-- Optional Pain Scale Assessment Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Nursing Note can only be used on Clinical Documents.
   </assert> 
   <!-- 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> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Nursing Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Note any missing optional elements -->
     Note: This Nursing Note Document does not contain a(n) Level of Conciousness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Nursing Note Document does not contain a(n) Pain Scale Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Nursing Note Document must contain a(n) Interventions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Nursing Note Document must contain a(n) Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2 
   </assert> 
 </rule>
</pattern>
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