1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
Development Only
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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.
<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'/> |
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>
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