1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
Development Only
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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 | LOINC |
|---|---|
| Level of Consciousness | |
| Vital Signs | |
| Pain Scale Assessment | 38212-7 Pain assessment panel |
| Interventions | 29554-3 Procedure |
| Assessment | |
| Medications Administered | |
| Intravenous Fluids Administered | |
| Procedures Performed | |
| 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 |
| 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 |
| Assessment Record any assessments of the patient condition |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 |
| 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.
<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> |
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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'>
<!-- 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 = "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 = " "]'>
<!-- 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>