Emergency Department Encounter Record

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Introduction

This is a draft of the Emergency Department Encounter Record (EDER) supplement to the Patient Care Coordination Technical Framework. This draft is a work in progress, not the official supplement or profile. A copy of the original profile proposal is here.

Profile Abstract

An Emergency Department "chart" is the entire collection of (multi-authored) documents and reports recording the assessments and care delivered by the entire ED team (including physicians, nurses, technologists and other providers) in response to an ED visit.

For the purposes of this integration profile, we define the Emergency Department Encounter Record (EDER) as a summary of the patient’s current health status and care rendered in the ED between arrival and ED departure. The EDER is not intended to replace the ED Chart as a complete, legal document of care, but is a collection of medical summaries with focused scope that are produced to fulfill a number of collaborative transfers of care.

Issue Log

Open Issues

  1. New LOINC codes for data elements
    • ED Referral Note
    • Pre-hospital Care Note (EMS Note)
    • ED Triage Note
    • ED Triage Note
    • Procedure Performed

Closed Issues

  1. The EDER is a multi-authored (but singly attested?) document. How should this best be implemented/reflected: Document to be attested to by ED attending physician.
  2. Patients frequently leave the ED prior to documentation being finalized. Triggers in workflow vary. How should the Draft vs. Final Status be handled: Only final documents will be posted to XDS.
  3. Potential for multiple entries: using folders, multiple sections do not occur.
  4. Timetable for CCD harmonization: done
  5. Target systems discussion: use case defined as EDIS posts to XDS.
  6. Use of Co-occurrence Constraint [Conditional Restraint] for Disposition elements: Yes.
  7. Snomed vs. DEEDS for Disposition: DEEDS

Glossary

Acuity Assessment
Also known as triage category, this is the acuity of the patient assigned during the process of ED triage. A number of evidenced based triage scales exist, including the Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), the Australasian Triage Scale (ATS), and the Manchester Triage System. In many emergency departments, patients may simply be classified as emergent, urgent or non-urgent.
EDIS
An Emergency Department Information System (EDIS) is an extended EHR system used to manage data in support of Emergency Department patient care and operations. The functions of an EDIS may be provided by a single application or multiple applications.
Mode of Arrival
The method of transportation used to transport the patient to the Emergency Department.
Referral Source
An individual, group, or agency that determined the patient should seek care at the ED. Referral source may be used to determine appropriate discharge referrals and services, or to provide surveillance data for program and service planning, or to examine referral patterns.

Systems

  • The Emergency Department Information System (EDIS) will produce an emergency department encounter record.
  • Both ambulatory and inpatient EHR-S will read and display this data.

Data Standards

  • Data Elements for Emergency Department Systems (DEEDS) 1.0
  • HL7 Version 3
  • HL7 CDA Release 2
  • HL7 CDA CCD
  • XML 1.0
  • IHE - Primary Care to ED Referral Request (2006)
  • IHE - Acute Care Discharge to Ambulatory Care Environment (2005)
  • IHE - Pre-procedure History and Physical (2006)

Technical Approach

The ED Encounter Record is a folder in XDS that defines a collection of documents. Separate content profiles must be created for the various kinds of documents that might be generated during an ED encounter. These content profiles include (existing and new):

  • Triage Note
  • Nursing Note
  • ED Physician Note
  • Pre-hospital Care Report
  • Diagnostic Imaging Reports
  • Laboratory Reports
  • Consultation Reports
  • Patient Consents for Treatment and Procedures
  • Transfer Summary
  • Summary of Death

As of this IHE cycle, we propose and define content profiles for Physician and Nursing documents within EDER.

It is expected that the transfers of care referred to in the use cases will occur in an environment where the EDIS, HIS, and Primary Care Physician EHR are coordinated within a Regional Health Information Organization (RHIO) environment or local community of care setting. As such a repository-based, or a peer-to-peer transfer of information is needed. It is expected that the XDS profile specified in the ITI Infrastructure domain would be the vehicle for transferring the EDER. HL7 CDA for creating XML-based extractions of the EMR will be constrained appropriately to reflect the inclusion of the sections/elements denoted in this use case. To ensure persistence of “care context” following the information transfer, an appropriate transformation Style Sheet (XSLT) will be described and included with the document. The subsequent care provider will use this transformed document as the default presentation option for the referral.

Risks

Both small and large EDIS product vendors must easily implement the solution defined. Simplified, iterative implementation approaches may need to be considered when identifying the technical solution. The solution must be able to accommodate multiple levels of “consumers” of these transfers of care documents. EHR-S or HIS vendors may choose not to engineer the ability to consume all elements in the EDER, but constrain machine readability to elements considered pertinent to their customers practice, such as new diagnoses, new prescriptions, medications administered during the visit, procedures performed, and disposition. Finally, time to implementation may constrain scope and or quality. The healthcare industry and Congress actively promote both EMR utilization and interoperability by its care practitioners and healthcare facilities. ONC through HITSP are currently This translates to numerous community-wide and medical societal-wide initiatives for the introduction of healthcare technology solutions by their constituents. As a side effect, expediency of action is important in order to be out ahead of these initiatives as much as possible to lead them in their decision/selection process. Care must be taken to ensure that the technical solution is able to be implemented expediently and engineered for change as feedback from these early initiatives is absorbed and reacted to by the healthcare industry. This work partially positions IHE to address the most recent AHIC challenge to ONC/HITSP for the development of an emergency response use case for EHR adoption, as the ED (and hence the ED encounter) figure prominently in the chain of information transfer outlined in the first drafts of this use case: http://www.hhs.gov/healthit/erehr.html.

Summary

Data released by the Centers for Disease Control and Prevention (CDC) estimates that there were over 110 million emergency department visits in 2004, making the emergency department (ED) chart (hereafter called encounter record) one of the most common medical summaries in use today. Currently, the ED encounter record remains largely a paper based artifact, and when produced by an Emergency Department information system (EDIS) is almost exclusively delivered as unstructured or loosely structured text. The ED chart is used to communicate the details of an emergency department visit in a variety of ways. The chart is most frequently faxed or mailed to primary care providers, and is increasingly archived electronically to hospital clinical data repositories. The original (or a copy) must accompany the patient to the ward upon hospital admission where is can be reviewed by hospital providers, or a copy may be sent with the patient on transfer from ED to ED or from ED to other medical treatment facilities. Unfortunately, these frequently become lost or misplaced. ED encounter records have no standardized format, and may be frequently be difficult to read by users unfamiliar with their formatting. None yet carry any semantic meaning that could be consumed by a receiving EHR system (EHR-S).

The production and delivery of the ED encounter record solves a number of problems, including:

  • Communication with and transfer of care back to the patient’s primary care physician.
  • Communication with care providers in the inpatient setting for patients admitted to the hospital from the emergency department.

The ED encounter record could also be employed in:

  • Transfer of information to hospital and provider billing systems.
  • Transfer of information to regulatory and public health agencies requesting data from emergency department encounters.

References

  1. Emergency Care Special Interest Group, Health Level 7:Emergency Department Information Systems (EDIS) Functional Profile. Draft Version 1.04 (3/2/2007)


Volume 1

Add the following bullet to the list of profiles
  • Emergency Department Encounter Record (EDER) as a summary of the patient’s current health status and a summary of care rendered in the ED between arrival and ED departure. The EDER is not (yet) intended to replace the ED Chart as a complete, legal document of care, but is intended as a collection of medical summaries with focused scope that can be used to fulfill a number of collaborative transfers of care. The ED encounter record may include links to diagnostic tests performed during the ED encounter, as well as links to an initial ED referral (a 2006 IHE work product), prehospital (EMS) records (IHE roadmap 2008), and the consultations of other providers for patients seen in the ED.

Use Case

Emergency Department Visit

This use case presumes the patient is cared for at a hospital facility with an EDIS as well as a hospital information system. Additionally, the patient’s primary care provider is also assumed to posses an interoperable EHR system. This use case begins upon the arrival of the patient to the emergency department. Data including mode of arrival, chief complaint, and other arrival data are manually entered into the EDIS. Additional data including past medical problems, medications and allergies, are obtained in one of the following ways:

  1. Entered manually into the EDIS by the triage nurse
  2. Imported from a legacy ED encounter within the EDIS
  3. Imported from the hospital information system or CDR, perhaps using Query for Existing Data.
  4. Imported from an Emergency Department Referral (IHE 2006-2007)
  5. Imported from a prehospital EMS report (Emergency Medical Services (EMS) to Emergency Dept Data Transfer, PCC Roadmap 2008-2009)

The patient undergoes assessments by a triage nurse, is assigned a triage category (i.e. emergent, urgent, non-urgent). The patient is then registered and demographic data is obtained. One taken to the treatment area, the patient undergoes additional assessments by a primary RN, and seen by an ED physician who performs a history and physical, orders various diagnostic tests, determines a course of therapy, orders medications to be administered in the ED and performs procedures on the patient. Upon completion of ED care, the patient is either admitted to the hospital, discharged from the ED, or transferred to another facility. Hence, the use case can take one of three branches:

  1. If admitted, the EDER is sent to the hospital information system where it can be viewed by providers, or read by the EHR system so that medical summary data and details of care rendered in the ED available to inpatient providers.
  2. If the patient is discharged the EDER is sent to the patients primary care physician as a summary of care rendered during the ED encounter.
  3. If the patient is transferred to another facility, the EDER is posted to the RHIO and made available for providers at the receiving facility.

Real-Life Example

Mr. John Smith, a longstanding patient of Dr. Mark Klein, is 62 year old man with hypertension and diabetes who awoke with acute onset of fever, right-sided chest pain and cough. He presents to the IHE ED via EMS where he is triaged by nurse Karen Ross who collects his past medical history, medications, allergies, mode of arrival, and inputs this data into the EDIS. Mr. Smith is taken directly to the treatment area where he is assigned to nurse Barbara Reiter who obtains vital signs, baseline pulse oximetry, places the patient on oxygen, and obtains IV access. She documents her assessments and interventions in the EDIS. The patient is seen by Dr. William Reed who performs and records a history and physical examination, orders an ECG, chest radiograph, CBC, electrolytes, and blood cultures. The chest radiograph reveals bi-lobar pneumonia and the ECG is slightly abnormal. Ceftriaxone 1gm IV plus Azythromycin 500mg PO are administered. After multiple attempts by Dr. Reed to contact Dr. Klein, Mr. Smith is admitted to a intermediate care bed under the care of Dr. Herman Edwards the IHE hospitalist. Upon hospital admission, Dr. Reed completes the record and, as the responsible attending physician, electronically signs the ED chart authenticating the EDER. The initial ED attending physician to see the patient is by default the legal authenticator, and may only delegate this responsibility to another provider through a formal transfer of care. The EDER is posted to the RHIO and also sent to the hospital information system. Using the HIS, the nurse on the intermediate care ward accesses the record and notes the time and administration of antibiotics. When Dr. Klein reaches the office in the morning, his office EHR-S notifies him that his patient was seen in the IHE ED the previous night, and displays the ED encounter record.

Actors

Volume 2

IHE Content Modules

Folder Content Specification

Trial.gif EDES Folder Specification

This is a content profile for the EDES folder. The EDES folder is a container for all documents created as a result of an ED encounter. These documents include, but are not limited to those described below. In the case of triage and nursing documentation, it is recognized that Triage Notes and ongoing ED Nursing Notes may or may not be documented the using the same form or EHR system. Therefore, these notes may either be sent separately, or in a Composite Triage and ED Nursing note.


Document Name Opt Template ID
Triage Note
If this document is sent, then an ED Nursing note is also required and a Composite Triage and ED Nursing Note may not be sent.		 C 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
ED Nursing Note
If this document is sent, then a Triage Note is also required and a Composite Triage and ED Nursing Note may not be sent.		 C 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2
Composite Triage and ED Nursing Note
If this note is sent, then neither the Triage Note, nor the ED Nursing note may be sent.		 C 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
ED Physician Note R 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
Prehospital Care Report R2
Diagnostic Imaging Reports R2
Lab Reports R2
Consultations R2
Transfer Summary R2
Summary of Death R2


CDA Release 2.0 Content Modules

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

Trial.gif Triage Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1

The triage note specification includes sections for data commonly captured during the initial triage assessment of the patient. It includes arrival data, historical information about the patient, vital signs, 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-TRIAGE Triage Note

Data Element Index
Data Element LOINC
Chief Complaint 10154-3 CHIEF COMPLAINT
Reason for Visit 29299-6 REASON FOR VISIT
Mode of Arrival 11459-5 TRANSPORT MODE
History of Present Illness 10164-2 HISTORY OF PRESENT ILLNESS
History of Past Illness 11348-0 HISTORY OF PAST ILLNESS
List of Surgeries 47519-4 HISTORY OF PRIOR SURGERIES
Immunizations 11369-6 HISTORY OF IMMUNIZATIONS
Family History 10157-6 HISTORY OF FAMILY ILLNESS
Social History 29762-2 SOCIAL HISTORY
History of Pregnancies 10162-6 HISTORY OF PREGNANCIES
Current Medications 10160-0 CURRENT MEDICATIONS
Allergies 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS
Acuity Assessment 11283-9 ACUITY ASSESSMENT
Vital Signs 8716-3 VITAL SIGNS
Assessments X-ASSESS ASSESSMENTS
Procedures and Interventions 29544-3 PROCEDURE
Medications Administered 18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered 8975-5 INTRAVASCULAR FLUID INTAKE
Specification
Data Element Name Opt Template ID
Chief Complaint R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Reason for Visit R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
Mode of Arrival R 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
History of Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
History of Past Illness R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries R2 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R2 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
History of Pregnancies
This section should contain one entry containing the date (TS) of last menstrual period for women of childbearing age, using LOINC Code 8665-2 DATE LAST MENSTRUAL PERIOD 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Current Medications R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Acuity Assessment R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
Vital Signs R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Assessments R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Procedures and Interventions R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Medications Administered R2 1.3.6.1.4.1.19376.1.5.3.1.3.21
Intravenous Fluids 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. 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.

Sample Triage Note Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1'/>
  <id root=' ' extension=' '/>
  <code code='X-TRIAGE' displayName='Triage Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Triage Note</title>
  <effectiveTime value='20240420012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1'/>
        <!-- Required Reason for Visit Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Mode of Arrival Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History of Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known History of Past Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required if known List of Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Required if known History of Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Medications Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2'/>
        <!-- Required Acuity Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- 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 if known Assessments 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 Intravenous Fluids Administered Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Triage 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 Triage Note is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "X-TRIAGE"]'>
     Error: The document type code of a Triage Note must be X-TRIAGE
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Reason for Visit Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Mode of Arrival Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) History of Past Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Triage Note Document must contain a(n) Acuity Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </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 Triage Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Triage Note Document should contain a(n) Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </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  Triage Note Document should contain a(n) Procedures and Interventions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </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  Triage Note Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </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  Triage Note Document should contain a(n) Intravenous Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
   </assert> 
 </rule>
</pattern>

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

Trial.gif 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 29544-3 PROCEDURE
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.

Sample ED Nursing Note Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.2'/>
  <id root=' ' extension=' '/>
  <code code='X-NN' displayName='Nursing Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>ED Nursing Note</title>
  <effectiveTime value='20240420012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- 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='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/>
        <!-- Optional Functional Status Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required 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 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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- 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 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>

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

Trial.gif Composite Triage and Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3

The Composite Triage and ED Nursing Note specification may be employed where the ED Triage Note and ED Nursing Notes exist within a single document. The elements below are an exact composite of the elements from the Triage Note specification and the ED Nursing Note specification.


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-TRIAGE Triage Note

Data Element Index
Data Element LOINC
Chief Complaint 10154-3 CHIEF COMPLAINT
Reason for Visit 29299-6 REASON FOR VISIT
Mode of Arrival 11459-5 TRANSPORT MODE
History of Present Illness 10164-2 HISTORY OF PRESENT ILLNESS
Past Medical History 11348-0 HISTORY OF PAST ILLNESS
List of Surgeries 47519-4 HISTORY OF PRIOR SURGERIES
Immunizations 11369-6 HISTORY OF IMMUNIZATIONS
Family History 10157-6 HISTORY OF FAMILY ILLNESS
Social History 29762-2 SOCIAL HISTORY
History of Pregnancies 10162-6 HISTORY OF PREGNANCIES
Current Medications 10160-0 CURRENT MEDICATIONS
Allergies 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS
Acuity Assessment 11283-9 ACUITY ASSESSMENT
Vital Signs 8716-3 VITAL SIGNS
Assessments X-ASSESS ASSESSMENTS
Functional Status Assessments 47420-5
Procedures and Interventions 29544-3 PROCEDURE
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
Chief Complaint R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Reason for Visit R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
Mode of Arrival R 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
History of Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Past Medical History R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
List of Surgeries R2 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R2 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
History of Pregnancies
This section should contain one entry containing the date (TS) of last menstrual period for women of childbearing age, using LOINC Code 8665-2 DATE LAST MENSTRUAL PERIOD 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Current Medications R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Acuity Assessment R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
Vital Signs R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Assessments R2 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 R2 1.3.6.1.4.1.19376.1.5.3.1.3.21
IV Fluids Administered R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
ED Disposition
The ED Disposition shall have a Mode of Transport entry describing how the patient departed. 		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.

Sample Composite Triage and Nursing Note Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3'/>
  <id root=' ' extension=' '/>
  <code code='X-TRIAGE' displayName='Triage Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Composite Triage and Nursing Note</title>
  <effectiveTime value='20240420012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1'/>
        <!-- Required Reason for Visit Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Mode of Arrival Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History of Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Past Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required if known List of Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Required if known History of Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Medications Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2'/>
        <!-- Required Acuity Assessment Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- 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 if known Assessments  Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1'/>
        <!-- Optional Functional Status Assessments Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required 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 IV Fluids Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required ED Disposition Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Composite Triage and 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 Composite Triage and Nursing Note is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "X-TRIAGE"]'>
     Error: The document type code of a Composite Triage and Nursing Note must be X-TRIAGE
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) Reason for Visit Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) Mode of Arrival Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Composite Triage and Nursing Note Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Composite Triage and Nursing Note Document should contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Composite Triage and Nursing Note Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Composite Triage and Nursing Note Document should contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Composite Triage and Nursing Note Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Composite Triage and Nursing Note Document should contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Composite Triage and Nursing Note Document must contain a(n) Acuity Assessment Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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 Composite Triage and Nursing Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Composite Triage and Nursing Note Document should contain a(n) Assessments  Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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 Composite Triage and Nursing Note Document does not contain a(n) Functional Status Assessments Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 
   </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 Composite Triage and Nursing Note Document must contain a(n) Procedures and Interventions Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 
   </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  Composite Triage and Nursing Note Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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  Composite Triage and Nursing Note Document should contain a(n) IV Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
   </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 Composite Triage and Nursing Note Document must contain a(n) ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 
   </assert> 
 </rule>
</pattern>

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

Trial.gif ED Physician Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4

The ED Physician note specification includes sections for data commonly reported by the physician as part of an ED encounter. It includes relevant historical information about the patient, pertinent arrival information, vital signs, history and physical examination findings, assessment and plan, interventions including medications, fluids and procedures, diagnosis and disposition.


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 28568-4 ED Visit Note

Data Element Index
Data Element LOINC
Referral Source 11293-8 ED REFERRAL SOURCE
Mode of Arrival 11459-5 TRANSPORT MODE
Chief Complaint 10154-3 CHIEF COMPLAINT
Reason for Visit 29299-6 REASON FOR VISIT
History of Present Illness 10164-2 HISTORY OF PRESENT ILLNESS
Advance Directives 42348-3 ADVANCE DIRECTIVES
Active Problems 11450-4 PROBLEM LIST
Past Medical History 11348-0 HISTORY OF PAST ILLNESS
Current Medications 10160-0 CURRENT MEDICATIONS
Allergies 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS
List of Surgeries 47519-4 History of procedures
Immunizations 11369-6 HISTORY OF IMMUNIZATIONS
Family History 10157-6 HISTORY OF FAMILY MEMBER DISEASES
Social History 29762-2 SOCIAL HISTORY
History of Pregnancies 10162-6 HISTORY OF PREGNANCIES
Pertinent ROS 10187-3 REVIEW OF SYSTEMS
Vital Signs 8716-3 VITAL SIGNS
Physical Examination 29545-1 PHYSICAL EXAMINATION
Assessment and Plan X-AANDP ASSESSMENT AND PLAN
X-ASSESS ASSESSMENT
18776-5 TREATMENT PLAN
Medications Administered 18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered X-IVFLU INTRAVENOUS FLUID ADMINISTERED
Procedures Performed 29544-3 PROCEDURE
Test Results - Lab, ECG, Radiology 30954-2 STUDIES SUMMARY
Consultations 18693-2 ED CONSULTANT PRACTITIONER
Progress Note 18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)
ED Diagnoses 11301-9 ED DIAGNOSIS
Medications at Discharge 10183-2 HOSPITAL DISCHARGE MEDICATIONS
ED Disposition 11302-7 ED DISPOSITION
Specification
Data Element Name Opt Template ID
Referral Source R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
Mode of Arrival R 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Chief Complaint R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
Reason for Visit R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1
History of Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Advanced Directives R 1.3.6.1.4.1.19376.1.5.3.1.3.34
Active Problems R2 1.3.6.1.4.1.19376.1.5.3.1.3.6
Past Medical History R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
Current Medications R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies R 1.3.6.1.4.1.19376.1.5.3.1.3.13
List of Surgeries R 1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations R 1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History R 1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History R 1.3.6.1.4.1.19376.1.5.3.1.3.16
History of Pregnancies
This section should contain one entry containing the date (TS) of last menstrual period for women of childbearing age, using LOINC Code 8665-2 DATE LAST MENSTRUAL PERIOD 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Pertinent ROS R2 1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
Physical Examination R 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Assessements
This section shall be present when assessments and plans are recorded separately. 		C 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Care Plan
This section shall be present when assessments and plans are recorded separately. 		C 1.3.6.1.4.1.19376.1.5.3.1.3.31
Assessment and Plan
This section shall be present when assessments and plans are recorded together. 		C 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
Medications Administered R2 1.3.6.1.4.1.19376.1.5.3.1.3.21
Intravenous Fluids Administered R2 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
Procedures Performed R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11
Test Results Lab, ECG, Radiology R 1.3.6.1.4.1.19376.1.5.3.1.3.27
Consultations R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8
Progress Note R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
ED Diagnoses R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
Medications at Discharge R2 1.3.6.1.4.1.19376.1.5.3.1.3.22
ED Disposition
The ED Disposition shall contain a mode of transport entry describing how the patient departed. 		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.

Sample ED Physician Note Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'/>
  <id root=' ' extension=' '/>
  <code code='28568-4' displayName='ED Visit Note'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>ED Physician Note</title>
  <effectiveTime value='20240420012005'/>
  <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='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3'/>
        <!-- Required Referral Source Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2'/>
        <!-- Required Mode of Arrival Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1'/>
        <!-- Required Reason for Visit Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History of Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required Advanced Directives Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Past Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Current Medications Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required List of Surgeries Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required Immunizations Section content -->
      </section>
    </component>

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

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Required if known History of Pregnancies Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required if known Pertinent ROS Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2'/>
        <!-- Required Vital Signs Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4'/>
        <!-- Conditional Assessements Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/>
        <!-- Conditional Assessment and Plan 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 Intravenous Fluids Administered Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11'/>
        <!-- Required Procedures Performed Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.27'/>
        <!-- Required Test Results Lab, ECG, Radiology Section content -->
      </section>
    </component>

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

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7'/>
        <!-- Required Progress Note Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9'/>
        <!-- Required ED Diagnoses Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.22'/>
        <!-- Required if known Medications at Discharge Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10'/>
        <!-- Required ED Disposition Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The ED Physician 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 Physician Note is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "28568-4"]'>
     Error: The document type code of a ED Physician Note must be 28568-4
   </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 = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Referral Source Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Mode of Arrival Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Reason for Visit Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Advanced Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Active Problems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Current Medications Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Allergies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) List of Surgeries Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) History of Pregnancies Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 
   </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  ED Physician Note Document should contain a(n) Pertinent ROS Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 Physician Note Document must contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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  ED Physician Note Document should contain a(n) Medications Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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  ED Physician Note Document should contain a(n) Intravenous Fluids Administered Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 Physician Note Document must contain a(n) Procedures Performed Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.27"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Test Results Lab, ECG, Radiology Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 ED Physician Note Document must contain a(n) Consultations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) Progress Note Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The ED Physician Note Document must contain a(n) ED Diagnoses Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.22"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  ED Physician Note Document should contain a(n) Medications at Discharge Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </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 Physician Note Document must contain a(n) ED Disposition Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4 
   </assert> 
   <assert test='((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])
              and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"])
               or (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]))
             and
              not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]))
             and
               not((.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"])
               and (.//cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.3.31"]))'>
     Error:  A(n) ED Physician Note shall contain either Assessments AND Care
     Plan OR Assessment and Plan. See
     http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4
   </assert> 
 </rule>
</pattern>
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