Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1"
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|The nursing evaluation and management note contains the information relevant to the six step nursing process described by the American Nursing Association Standards of Nursing Practice (ANA 2004). These include: | |The nursing evaluation and management note contains the information relevant to the six step nursing process described by the American Nursing Association Standards of Nursing Practice (ANA 2004). These include: | ||
* Assessment<br/>The assessment includes nursing assessments, review of systems and/or physical examination details and vital signs as necessary, as well as any necessary assessments of functional status or risks to the patient. Additional sections may be added to include relevant family / social history, or other key knowledge necessary to the implementation of the nursing plan. | * Assessment<br/>The assessment includes nursing assessments, review of systems and/or physical examination details and vital signs as necessary, as well as any necessary assessments of functional status or risks to the patient. Additional sections may be added to include relevant family / social history, or other key knowledge necessary to the implementation of the nursing plan. | ||
| − | * Nursing Diagnosis<br/>The problem list section includes any nursing and physician diagnoses that are relevant to | + | * Nursing Diagnosis<br/>The problem list section includes any nursing and physician diagnoses that are relevant to or being treated by the care plan. |
| − | * Planning<br/>Planning includes identification of goals and the treatments and | + | * Planning<br/>Planning includes identification of outcomes (goals) and the treatments and interventions to be implemented under the plan. |
| − | ** Orders<br/>The care plan | + | ** Orders<br/>The care plan must include a subsection documenting provider orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera) and monitoring (testing, monitoring, et cetera). |
| − | |||
* Implementation<br/>The procedures and interventions section is used to report the interventions and care provided to the patient. | * Implementation<br/>The procedures and interventions section is used to report the interventions and care provided to the patient. | ||
* Evaluation<br/>The progress notes section is where the evaluation of the effectiveness of the plan towards the goals is documented, and may include assessments of the patient response to the treatment plan. | * Evaluation<br/>The progress notes section is where the evaluation of the effectiveness of the plan towards the goals is documented, and may include assessments of the patient response to the treatment plan. | ||
| Line 16: | Line 15: | ||
{{R|Assessment|X-ASSESS ASSESSMENTS}} | {{R|Assessment|X-ASSESS ASSESSMENTS}} | ||
{{R|Active Problems|11450-4 PROBLEM LIST}} | {{R|Active Problems|11450-4 PROBLEM LIST}} | ||
| + | {{R|Care Plan|18776-5 Plan of Treatment}} | ||
| + | {{R| Provider Orders|46209-3 PROVIDER ORDERS}} | ||
{{R|Procedures and Interventions|29544-3 Procedures}} | {{R|Procedures and Interventions|29544-3 Procedures}} | ||
| − | |||
| − | |||
{{R|Progress|27574-3 Progress Note and Attainment of Goals}} | {{R|Progress|27574-3 Progress Note and Attainment of Goals}} | ||
}} | }} | ||
|Section|Active Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6| | |Section|Active Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6| | ||
}} | }} | ||
Revision as of 10:20, 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
Care Plan Specification 1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1
The nursing evaluation and management note contains the information relevant to the six step nursing process described by the American Nursing Association Standards of Nursing Practice (ANA 2004). These include:
- Assessment
The assessment includes nursing assessments, review of systems and/or physical examination details and vital signs as necessary, as well as any necessary assessments of functional status or risks to the patient. Additional sections may be added to include relevant family / social history, or other key knowledge necessary to the implementation of the nursing plan. - Nursing Diagnosis
The problem list section includes any nursing and physician diagnoses that are relevant to or being treated by the care plan. - Planning
Planning includes identification of outcomes (goals) and the treatments and interventions to be implemented under the plan.- Orders
The care plan must include a subsection documenting provider orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera) and monitoring (testing, monitoring, et cetera).
- Orders
- Implementation
The procedures and interventions section is used to report the interventions and care provided to the patient. - Evaluation
The progress notes section is where the evaluation of the effectiveness of the plan towards the goals is documented, and may include assessments of the patient response to the treatment plan.
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 |
| Active Problems | 11450-4 PROBLEM LIST |
| Care Plan | 18776-5 Plan of Treatment |
| Provider Orders | 46209-3 PROVIDER ORDERS |
| Procedures and Interventions | 29544-3 Procedures |
| 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.
<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='20240424012005'/> <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> |
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>