1.3.6.1.4.1.19376.1.5.3.1.1.20.1.1
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 components of the 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. - Expected Outcomes
Identification of the expected outcomes for the patient (the goals). - Planning
Planning describes the treatments and interventions to be implemented to reach the expected outcomes under the plan.- Orders
The care plan must include a subsection referencing provider orders and actions that are to be implemented, including any orders for treatment (e.g., medications, therapy, et cetera), monitoring (testing, monitoring, et cetera), education.
- Orders
- Implementation
The procedures and interventions section is used to report the actions performed 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 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 |
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.
<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='20240329012005'/> <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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/> <!-- Required Assessments 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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> <!-- 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>
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.18
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.14
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.16
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.6
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.31
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.20.2.1
- 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
- CDA Document Templates