1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
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 http://www.ihe.net/Technical_Framework/index.cfm#PCC
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 | 1.3.6.1.4.1.19376.1.5.3.1.3.25 |
| Assessments Record of assessments of the patient's condition |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 |
| Level of Consciousness | O | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 |
| Pain Scale Assessment | O | 1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1 |
| Interventions Record the interventions performed |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 |
| Medications Administered | R | 1.3.6.1.4.1.19376.1.5.3.1.3.21 |
| 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='1.3.6.1.4.1.19376.1.5.3.1.3.25'/> <!-- 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'>
<!-- 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"]'>
<!-- Verify that all required data elements are present -->
Error: The Nursing Note Document must contain a(n) Assessments Section.
See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
</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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.3.1"]'>
<!-- 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'>
<!-- 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>