1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1

Development Only

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Care Plan Specification 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1

Description

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

Data Element Index

Data Element	LOINC
Assessment	X-ASSESS ASSESSMENTS
Provider Orders	46209-3 PROVIDER ORDERS
Active Problems	11450-4 PROBLEM LIST
Procedures and Interventions	29544-3 Procedures
Care Plan	18776-5 Plan of Treatment
Progress	27574-3 Progress Note and Attainment of Goals

Specification

Data Element Name	Opt	Template ID
Active Problems	R	1.3.6.1.4.1.19376.1.5.3.1.3.6

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='20240811012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Active Problems 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 = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Active Problems 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> 
 </rule>
</pattern>