1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2

Development Only

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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
Nursing Assessments	X-ASSES-X NURSING ASSESSMENT
Nursing Interventions	NURIN-T NURSING INTERVENTIONS
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered	XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)
ED Disposition	11302-7 ED DISPOSITION

Specification

Data Element Name	Opt	Template ID
Vital Signs	R	1.3.6.1.4.1.19376.1.5.3.1.3.25
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
Interventions This section is used to record 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	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
ED Disposition	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8

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='20240506012005'/>
  <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>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
        <!-- Required Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/>
        <!-- Required Interventions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
        <!-- Required Medications Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'/>
        <!-- Required Intravenous Fluids Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8'/>
        <!-- Required ED Disposition Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]'> 
     <!-- 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 = "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 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8"]'> 
     <!-- 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>

Sections

1.3.6.1.4.1.19376.1.5.3.1.3.25
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
1.3.6.1.4.1.19376.1.5.3.1.3.21
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8