1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4

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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

NURSING ASSESSMENTS Section
Template ID 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Parent Template Triage Note (1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1)
General Description The assessment section contains all nursing patient assessments. Assessments may be narrative. If specific assessments of pain or level of consciousness are included, they should appear in the respective sub-section. Pain and level of consciousness may also contain entries. only the required and optional subsections performed.
LOINC Codes Opt Description
XASSES-X R NURSING ASSESSMENTS
Subsections Opt Description
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9 O Pain Scale
Pain Scale must be a subsection of the assessments section and may not stand alone.
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 O Level of Consciousness
Level of consciousness must be a subsection of the assessments section and may not stand alone.



Parent Template

The parent of this template is Triage Note.

Sample NURSING ASSESSMENTS Section
<component>
  <section>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text>
<component> Required and optional subsections as described above </component>     </section> </component>


Uses

See Templates using the NURSING ASSESSMENTS Section