1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1

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Care Plan Specification 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1

The nursing evaluation and management note contains the information relevant to the six step nursing process described by the American Nursing Association Standards of Nursing Practice (ANA 2004). These include:

• Assessment
  The assessment includes nursing assessments, review of systems and/or physical examination details and vital signs as necessary, as well as any necessary assessments of functional status or risks to the patient. Additional sections may be added to include relevant family / social history, or other key knowledge necessary to the implementation of the nursing plan.
• Nursing Diagnosis
  The problem list section includes any nursing and physician diagnoses that are relevant to or being treated by the care plan.
• Planning
  Planning includes identification of outcomes (goals) and the treatments and interventions to be implemented under the plan.
  • Orders
    The care plan must include a subsection documenting provider orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera) and monitoring (testing, monitoring, et cetera).
• Implementation
  The procedures and interventions section is used to report the interventions and care provided to the patient.
• Evaluation
  The progress notes section is where the evaluation of the effectiveness of the plan towards the goals is documented, and may include assessments of the patient response to the treatment plan.

LOINC Code

The LOINC code for this document is 34746-8 Nursing Evaluation and Management Note

Standards

CDAR2	HL7 CDA Release 2.0
CCD	ASTM/HL7 Continuity of Care Document
ANA 2004	[ ]

Data Element Index

Data Element	LOINC	ANA 2004
Assessment	X-ASSESS ASSESSMENTS	Assessment
Active Problems	11450-4 PROBLEM LIST	Nursing Diagnosis
Care Plan	18776-5 Plan of Treatment	Planning and Outcome Identification
Provider Orders	46209-3 PROVIDER ORDERS	Planning
Procedures and Interventions	29544-3 PROCEDURES	Implementation
Medications Administered	18610-6 MEDICATION ADMINISTERED	Implementation
Progress	27574-3 Progress Note and Attainment of Goals	Evaluation

Specification

Data Element Name	Opt	Template ID
Assessments This section shall include all assessments performed.	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
Functional Status Assessment This section shall include any assessments of functional status that were performed on on the patient.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Physical Examination The physical examination section shall be present when a physical examination is performed during the assessment of the patient.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Review of Systems Section	R2	[[Category:Templates using ]]
R Section	C	[[Category:Templates using ]]
R Section	C	The care plan section shall include a subsection documenting the provider orders. [[Category:Templates using The care plan section shall include a subsection documenting the provider orders. ]]
R2 Section	C	This section shall be present when procedures and interventions are performed. [[Category:Templates using This section shall be present when procedures and interventions are performed. ]]
R2 Section	C	This section shall be present when medications have been administered. [[Category:Templates using This section shall be present when medications have been administered. ]]
R2 {{{49}}}	C	This section shall be present when IV fluids have been administered. [[Category:Templates using This section shall be present when IV fluids have been administered. ]]

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 Care Plan Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1'/> <id root=' ' extension=' '/> <code code='34746-8' displayName='Nursing Evaluation and Management Note' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Care Plan</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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'/> <!-- Required Assessments Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/> <!-- Required if known Functional Status Assessment Section content --> </section> </component>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/> <!-- Required if known Physical Examination Section content --> </section> </component>     </structuredBody></component> </ClinicalDocument>

Schematron

<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Care Plan can only be used on Clinical Documents.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "34746-8"]'>
     Error: The document type code of a Care Plan must be 34746-8
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Functional Status Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "

"]'> 

     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "

"]'>

     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "The care plan section shall include a subsection documenting the provider orders.

"]'>

     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "This section shall be present when procedures and interventions are performed.

"]'>

     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "This section shall be present when medications have been administered.

"]'>

     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "This section shall be present when IV fluids have been administered.

"]'>

     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
 </rule>
</pattern>