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

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Data Element Index

Data Element	A	LOINC
Acuity
Vital Signs
Pain Scale Assessment
Interventions
Assessment

-->>Data<<--

Specification

Data Element Name	Opt	Template ID
Acuity If necessary, record the patient's level of conciousness	O
Vital Signs	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>     </structuredBody></component> </ClinicalDocument>

 

   <!-- 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>