Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1"

Revision as of 12:02, 2 May 2009

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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), monitoring (testing, monitoring, et cetera), education and follow-up care.
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
ANA 2004	ANA Nursing Scope and Standard of Practice

Data Element Index

Data Element	LOINC	ANA 2004
Assessment	X-ASSESS ASSESSMENTS	Assessment
Physical Examination	29545-1 PHYSICAL EXAMINATION	Assessment
Review of Systems	10187-3 REVIEW OF SYSTEMS	Assessment
Functional Status Assessment	47420-5 Functional Status Assessment	Assessment
Family History	10157-6 HISTORY OF FAMILY MEMBER DISEASES	Assessment
Social History	29762-2 SOCIAL HISTORY	Assessment
Active Problems	11450-4 PROBLEM LIST	Nursing Diagnosis
Care Plan	18776-5 Plan of Treatment	Planning and Outcome Identification
Provider Orders	46209-3 PROVIDER ORDERS	Planning
Procedures and Interventions	29544-3 PROCEDURES	Implementation
Medications Administered	18610-6 MEDICATION ADMINISTERED	Implementation
Fluids Administered	8975-5 INTRAVASCULAR FLUID INTAKE	Implementation
Progress	27574-3 Progress Note and Attainment of Goals	Evaluation

Specification

Data Element Name	Opt	Template ID
Assessments This section shall include all assessments performed.	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
Physical Examination The physical examination section shall be present when a physical examination is performed during the assessment of the patient.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Review of Systems The review of systems section shall be present when a review of systems is performed during the assessment of the patient.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.18
Functional Status Assessment This section shall include any assessments of functional status that were performed on on the patient.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Family History	O	1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History	O	1.3.6.1.4.1.19376.1.5.3.1.3.16
Active Problems The problem list section includes any nursing and physician diagnoses that are relevant to or being treated by the care plan.	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Care Plan The care plan section shall include a subsection documenting the provider orders.	R	1.3.6.1.4.1.19376.1.5.3.1.3.31
Provider Orders orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera), monitoring (testing, monitoring, et cetera), education and follow-up care.	R	1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1
Procedures and Interventions This section shall be present when procedures and interventions are performed.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Medications Administered This section shall be present when medications have been administered.	R2	1.3.6.1.4.1.19376.1.5.3.1.3.21
Intraveneous Fluids Administered This section shall be present when IV fluids have been administered.	R2	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6

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='20240418012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6'/>
        <!-- Required Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required if known Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required if known Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/>
        <!-- Required if known Functional Status Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
        <!-- Optional Family History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
        <!-- Optional Social History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required Active Problems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.31'/>
        <!-- Required Care Plan Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1'/>
        <!-- Required Provider Orders Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required if known Procedures and Interventions Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.21'/>
        <!-- Required if known 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 if known Intraveneous Fluids Administered 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Physical Examination 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Review of Systems 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Functional Status Assessment 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Document does not contain a(n) Family History 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Care Plan Document does not contain a(n) Social History 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> 
   <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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.31"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Care Plan 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Care Plan Document must contain a(n) Provider Orders 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> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Procedures and Interventions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Care Plan Document should contain a(n) Intraveneous Fluids Administered 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>

@@ Line 36: / Line 36: @@
 |Section|Active Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|The problem list section includes any nursing and physician diagnoses that are relevant to or being treated by the care plan.
 |Section|Care Plan|R|1.3.6.1.4.1.19376.1.5.3.1.3.31|The care plan section shall include a subsection documenting the provider orders.
-|Section|Provider Orders|R|1.3.6.1.4.1.19376.1.5.3.1.1.20.3.1|orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera), monitoring (testing, monitoring, et cetera), education and follow-up care.
+|Section|Provider Orders|R|1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1|orders that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera), monitoring (testing, monitoring, et cetera), education and follow-up care.
 |Section|Procedures and Interventions|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11|This section shall be present when procedures and interventions are performed.
 |Section|Medications Administered|R2|1.3.6.1.4.1.19376.1.5.3.1.3.21|This section shall be present when medications have been administered.
 |Section|Intraveneous Fluids Administered|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6|This section shall be present when IV fluids have been administered.
 }}