Nursing Note Profile

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Nursing Note

The nursing note is a CDA document that may be submitted to an ED Folder in order to record the act of nursing care delivered to a patient in the emergency department. The ED nursing note is designed to support documentation sufficient to support transfer of care. It is recognized that the ED Nursing Note specification is not sufficient to document all medicolegal facets of care, and conversely that providers may not capture the entire list of sections, owing to patient presentation, acuity or time constraints.

Grouping

Cross Enterprise Document Sharing, Media Interchange and Reliable Messages

Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content Consumer sharing function of this profile. A Content Creator or Content Consumer may be grouped with appropriate actors from the XDS, XDM or XDR profiles to exchange the content described therein. The metadata sent in the document sharing or interchange messages has specific relationships or dependencies (which we call bindings) to the content of the clinical document described in the content profile.

The Patient Care Coordination Technical Framework defines the bindings to use when grouping the Content Creator of this Profile with actors from the IHE ITI XDS, XDM or XDR Integration Profiles.

Content Binding Actor Optionality
Nursing Note Medical Document Binding to XDS, XDM and XDR Content Creator R
Content Consumer R