Transaction: Nursing summary report
General information
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2021-06-01
DEFINITION:
This type of transaction corresponds to a nursing summary report that is expressed using a PDF until further evolution of this specification.
In the field, such a report might also functionally fulfill transfer of care requirements and be known as a 'nursing transfer report'. The kmehr message however will always be identified as a 'nursing summary report'.
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.0
DATE:
2021-06-01
DEFINITION:
This type of transaction corresponds to a nursing summary report that is expressed using a PDF until further evolution of this specification.
In the field, such a report might also functionally fulfill transfer of care requirements and be known as a 'nursing transfer report'. The kmehr message however will always be identified as a 'nursing summary report'.
Guidelines
Generalities
This transaction only requires a level 1 of kmehr normalization. Some additional guidelines must be fulfilled concerning the functional content.
Transaction elements
|
id |
id of the transaction according to the ID-KMEHR conventions. |
|
cd |
Use the value "nursingsummaryreport" from CD-TRANSACTION. It is allowed to add own local codes. |
|
date |
This is the date of reporting. |
|
time |
This is the time of reporting. |
|
author |
This is the person assuming the responsibility of the medical content of the transaction. It can be specified by a combination of hcparty elements. There must be at least one hcparty identifying a person. |
|
iscomplete |
Expresses whether the report is completed. Must be “true”. |
|
isvalidated |
Expresses whether the report is validated. Must be “true”. |
Structure overview
A nursing summary report is composed of the following element:
- lnk element to an internal PDF object
Functional content
No specific structured items are currently defined in the context of this transaction.
The report contains at least the following key elements for the follow-up of the patient by another healthcare provider or in the context of an envisaged hospitalization:
- anamnesis
- administrative data of the patient
- administrative data of the care team
- current nursing diagnoses
- which problem is treated in a collaborative effort
- list & description of the current cares that are given
- most recent KATZ evaluation
- 10 latest observations
- the values of the vital parameters of the last month or the last 10 measuring points
- contact details of the nursing party who is responsible for the care
Generalities
This transaction only requires a level 1 of kmehr normalization. Some additional guidelines must be fulfilled concerning the functional content.
Transaction elements
|
id |
id of the transaction according to the ID-KMEHR conventions. |
|
cd |
Use the value "nursingsummaryreport" from CD-TRANSACTION. It is allowed to add own local codes. |
|
date |
This is the date of reporting. |
|
time |
This is the time of reporting. |
|
author |
This is the person assuming the responsibility of the medical content of the transaction. It can be specified by a combination of hcparty elements. There must be at least one hcparty identifying a person. |
|
iscomplete |
Expresses whether the report is completed. Must be “true”. |
|
isvalidated |
Expresses whether the report is validated. Must be “true”. |
Structure overview
A nursing summary report is composed of the following element:
- lnk element to an internal PDF object
Functional content
No specific structured items are currently defined in the context of this transaction.
The report contains at least the following key elements for the follow-up of the patient by another healthcare provider or in the context of an envisaged hospitalization:
- anamnesis
- administrative data of the patient
- administrative data of the care team
- current nursing diagnoses
- which problem is treated in a collaborative effort
- list & description of the current cares that are given
- most recent KATZ evaluation
- 10 latest observations
- the values of the vital parameters of the last month or the last 10 measuring points
- contact details of the nursing party who is responsible for the care