1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2

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Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2

The Nursing note specification includes sections for data commonly captured during the ongoing care of the ED patient. It includes vital signs, ongoing assessments, and interventions.

Data Element Index

Data Element	LOINC
Vital Signs	8716-3 VITAL SIGNS
Assessment
Level of Consciousness
Pain Scale Assessment	38212-7 Pain assessment panel
Interventions	29554-3 Procedure
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered
ED Disposition	11302-7 ED DISPOSITION

Specification

Data Element Name	Opt	Template ID
Vital Signs	R	1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Assessment Record any assessments of the patient condition	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
Level of Consciousness	O	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
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	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
Medications Administered	R
Intravenous Fluids Administered	R
Procedures Performed	R
ED Disposition	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='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/> <!-- Required Vital Signs Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3'/> <!-- Required Assessment Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/> <!-- Optional Level of Consciousness Section content --> </section> </component>  <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>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/> <!-- Required Interventions 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> 
     <!-- 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3"]'> 
     <!-- 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Note any missing optional elements -->
     Note: This Nursing Note Document does not contain a(n) Level of Consciousness 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]'> 
     <!-- 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) Medications Administered 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) Intravenous Fluids Administered 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) Procedures Performed 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) ED Disposition 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>