Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2"
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{{R|Vital Signs|8716-3 VITAL SIGNS|}} | {{R|Vital Signs|8716-3 VITAL SIGNS|}} | ||
{{R|Assessments|X-ASSESS ASSESSMENTS}} | {{R|Assessments|X-ASSESS ASSESSMENTS}} | ||
− | {{ | + | {{R|Functional Status Assessments|47420-5}} |
{{R|Procedures and Interventions|X-PROC PROCEDURES PERFORMED}} | {{R|Procedures and Interventions|X-PROC PROCEDURES PERFORMED}} | ||
{{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)}} | {{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)}} |
Revision as of 11:08, 2 May 2009
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
ED Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
The ED 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.
Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:edes:2007
Parent Template
This document is an instance of the Medical Document template.
LOINC Code
The LOINC code for this document is X-NN Nursing Note
Data Element Index
Data Element | LOINC |
---|---|
Vital Signs | 8716-3 VITAL SIGNS |
Assessments | X-ASSESS ASSESSMENTS |
Functional Status Assessments | 47420-5 |
Procedures and Interventions | X-PROC PROCEDURES PERFORMED |
Medications Administered | 18610-6 MEDICATION ADMINISTERED (COMPOSITE) |
Intravenous Fluids Administered | X-IVFLU INTRAVENOUS FLUID ADMINISTERED (COMPOSITE) |
ED Disposition | 11302-7 ED DISPOSITION |
Specification
Data Element Name | Opt | Template ID |
---|---|---|
Vital Signs | R | 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2 |
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 |
Functional Status Assessments Record of assessments of patient's functional status |
O | 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1 |
Procedures and Interventions This section is used to record interventions or nursing procedures performed |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11 |
Medications Administered | R | 1.3.6.1.4.1.19376.1.5.3.1.3.21 |
Intravenous Fluids Administered | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 |
ED Disposition | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10 |
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. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/> |
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 ED Nursing Note can only be used on Clinical Documents. </assert> <!-- Verify that the parent templateId is also present. --> <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'> Error: The parent template identifier for ED Nursing Note is not present. </assert> <!-- Verify the document type code --> <assert test='cda:code[@code = "X-NN"]'> Error: The document type code of a ED Nursing Note must be X-NN </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 ED 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 ED 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> <!-- Note any missing optional elements --> Note: This ED Nursing Note Document does not contain a(n) Functional Status 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> <!-- Verify that all required data elements are present --> Error: The ED Nursing Note Document must contain a(n) Procedures and 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 ED 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> <!-- Verify that all required data elements are present --> Error: The ED 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10"]'> <!-- Verify that all required data elements are present --> Error: The ED 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>
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.21
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
- CDA Document Templates