1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4: Difference between revisions

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{{HL7V3|Nursing Assessments Battery|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|Comment|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|ED Diagnosis|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9|Comment|The ED diagnosis section shall contain a narrative description of the conditions that were diagnosed or addressed during the ED course, as well as those active conditions that modify the complexity of the patient encounter. It should include entries for patient conditions as described in the Entry Content Module.
|Example=<br/>
|LOINC=11301-9|LOINCName=ED DIAGNOSIS
<entry>
|Entry|Conditions Entry|R|1.3.6.1.4.1.19376.1.5.3.1.4.5|}}
  <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=' '/>
    &lt;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.
===== &lt;code code='(XASSES-X)' codeSystem='2.16.840.1.113883.6.1'/> =====
The &lt;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 Observations}}.  The following table lists the allowable LOINC codes, displayNames, and observation types for these observations.
{|border=1
|-bgcolor='#d9d9d9'
!code
!displayName
!xsi:type
!value set
|-
|9269-2
|GLASGOW COMA SCORE.TOTAL
|CO
|3..15
|-
|9268-4
|GLASGOW COMA SCORE.MOTOR
|CO
|1..6
|-
|11454-6
|LEVEL OF RESPONSIVENESS
|CO
|
ALERT
VERBAL RESPONSE
PAINFUL RESPONSE
UNRESPONSIVE
UNKNOWN
|-
|38208-5
|PAIN SEVERITY
|CO
|0-10
|-
|48767-8
|(COMMENT FIELD)
|ED
|
|-
|}

Revision as of 16:58, 23 August 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 https://www.ihe.net/resources/technical_frameworks/#pcc

ED Diagnosis Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
General Description The ED diagnosis section shall contain a narrative description of the conditions that were diagnosed or addressed during the ED course, as well as those active conditions that modify the complexity of the patient encounter. It should include entries for patient conditions as described in the Entry Content Module.
LOINC Code Opt Description
11301-9 R ED DIAGNOSIS
Entries Opt Description
1.3.6.1.4.1.19376.1.5.3.1.4.5 R Conditions Entry



Sample ED Diagnosis Section 
<component>
  <section>
    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'/>
    <id root=' ' extension=' '/>
    <code code='11301-9' displayName='ED DIAGNOSIS'
      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
    <text>
      Text as described above
    </text>   
    <entry>
         :
      <!-- Required Conditions Entry element -->
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5'/>
         :
    </entry>
       
  </section>
</component>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'> 
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9"]'> 
     <!-- Verify that the template id is used on the appropriate type of object --> 
   <assert test='../cda:section'> 
      Error: The ED Diagnosis can only be used on sections. 
   </assert> 
   <!-- Verify the section type code --> 
   <assert test='cda:code[@code = "11301-9"]'> 
     Error: The section type code of a ED Diagnosis must be 11301-9 
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.4.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Diagnosis Section must contain a(n) Conditions Entry Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
   </assert> 
 </rule> 
</pattern>
Uses

See Templates using the ED Diagnosis Section


}}

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