1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3: Difference between revisions

Latest revision as of 11:13, 2 May 2009

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

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='20260407012005'/>
  <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>

@@ Line 1: / Line 1: @@
-{{CDA Document|ED Physician Note|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3|Comment|
+{{CDA Document|Composite Triage and Nursing Note|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3|Trial|
-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.
+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.
+|formatCode=urn:ihe:pcc:edes:2007|Index={{T|Data Element|LOINC|Rows=
-|
+{{R|Chief Complaint|10154-3 CHIEF COMPLAINT|}}
-Index={{T|Data Element|LOINC|Rows=
+{{R|Reason for Visit|29299-6 REASON FOR VISIT|}}
-{{R|Referral Source|11293-8 ED REFERRAL SOURCE|}}
 {{R|Mode of Arrival|11459-5 TRANSPORT MODE|}}
-{{R|Chief Complaint|10154-3 CHIEF COMPLAINT FIND|}}
 {{R|History of Present Illness|10164-2 HISTORY OF PRESENT ILLNESS|}}
-{{R|Active Problems|10160-0 HISTORY OF MEDICATION USE|}}
+{{R|Past Medical History|11348-0 HISTORY OF PAST ILLNESS|}}
-{{R|Current Medications|10160-0 CURRENT MEDICATIONS|}}
+{{R|List of Surgeries|47519-4 HISTORY OF PRIOR SURGERIES|}}
-{{R|Allergies|X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS|}}
-{{R|List of Surgeries|10167-5 HISTORY OF SURGICAL PROCEDURES|}}
 {{R|Immunizations|11369-6 HISTORY OF IMMUNIZATIONS|}}
-{{R|Family History|10157-6 HISTORY OF FAMILY MEMBER DISEASES|}}
+{{R|Family History|10157-6 HISTORY OF FAMILY ILLNESS|}}
 {{R|Social History|29762-2 SOCIAL HISTORY|}}
-{{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES|}}
+{{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES}}
-{{R|LMP|8665-2 DATE LAST MENSTRUAL PERIOD|}}
+{{R|Current Medications|10160-0 CURRENT MEDICATIONS|}}
-{{R|Pertinent ROS|10187-3 REVIEW OF SYSTEMS|}}
+{{R|Allergies|48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS|}}
-{{R|Vital Signs||}}
+{{R|Acuity Assessment|11283-9 ACUITY ASSESSMENT|}}
-{{R|Physical Examination|22029-3 PHYSICAL EXAM.TOTAL|}}
+{{R|Vital Signs|8716-3 VITAL SIGNS|}}
-{{R|Assessment|X-AAPLN ASSESSMENT AND PLAN|}}
+{{R|Assessments|X-ASSESS ASSESSMENTS|}}
-{{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)|}}
+{{R|Functional Status Assessments|47420-5}}
-{{R|Intravenous Fluids Administered||}}
+{{R|Procedures and Interventions|29544-3 PROCEDURE|}}
-{{R|Procedures Performed|XXXXX-X PROCEDURE PERFORMED|}}
+{{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)}}
-{{R|Test Results: Lab, ECG, Radiology|30954-2 STUDIES SUMMARY|}}
+{{R|Intravenous Fluids Administered|X-IVFLU INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)}}
-{{R|Consultations|11488-4 CONSULTATION NOTE {SETTING} ATTACH.CLINRPT|}}
+{{R|ED Disposition|11302-7 ED DISPOSITION}}
-{{R|Progress Note|18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)|}}
-{{R|ED Diagnoses|11301-9 ED DIAGNOSIS|}}
-{{R|ED Disposition|11302-7 ED DISPOSITION|}}
-{{R|(Admission) Inpatient Facility|LOINC???|}}
-{{R|(Admission) Inpatient Practitioner|18774-0 STAFF PRACTITIONER NAME ???|}}
-{{R|(Discharge) Discharge Medications|18617-1 MEDICATION DISCHARGE ???|}}
-{{R|(Discharge) Discharge Instructions|8653-8	HOSPITAL DISCHARGE INSTRUCTIONS	???|}}
-{{R|(Discharge) Referral at ED Disposition|11303-5 ED DISPOSITION CONSULT/REFERRAL|}}
-{{R|(Discharge) ED Referral Practitioner|39266-2 FOLLOW-UP (REFERRED TO) PROVIDER/SPECIALIST|}}
-{{R|(Transfer) Facility Receiving ED Patient|11453-8 RECEIVING FACILITY|}}
-{{R|(Transfer) Accepting Practitioner|11303-5 ED DISPOSITION CONSULT/REFERRAL ???|}}
 }}
-|Data=
+|LOINC=X-TRIAGE|LOINCName=Triage Note
-{{CDA Document Content| |Referral Source|R| |}}
+|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.1|ParentName=Medical Document
-{{CDA Document Content| |Mode of Arrival|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|}}
+|Section|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1|}}
+|Section|Reason for Visit|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1.1|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4|}}
+|Section|Mode of Arrival|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|
-{{CDA Document Content| |Active Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|}}
+|Section|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4|
-{{CDA Document Content| |Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|}}
+|Section|Past Medical History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.8|
-{{CDA Document Content| |Alergies|R| |}}
+|Section|List of Surgeries|R2|1.3.6.1.4.1.19376.1.5.3.1.3.11|
-{{CDA Document Content| |List of Surgeries|R|1.3.6.1.4.1.19376.1.5.3.1.3.11|}}
+|Section|Immunizations|R2|1.3.6.1.4.1.19376.1.5.3.1.3.23|
-{{CDA Document Content| |Immunizations|R|1.3.6.1.4.1.19376.1.5.3.1.3.23|}}
+|Section|Family History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.14|
-{{CDA Document Content| |Family History|R|1.3.6.1.4.1.19376.1.5.3.1.3.14|}}
+|Section|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16|
-{{CDA Document Content| |Social History|R|1.3.6.1.4.1.19376.1.5.3.1.3.16|}}
+|Section|History of Pregnancies|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|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
-{{CDA Document Content| |History of Pregnancies|R| |}}
+|Section|Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|
-{{CDA Document Content| |LMP|R| |}}
+|Section|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|
-{{CDA Document Content| |Pertinent ROS|R|1.3.6.1.4.1.19376.1.5.3.1.3.18|}}
+|Section|Acuity Assessment|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Vital Signs|R||}}
+|Section|Vital Signs|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3|Physical Examination|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|}}
+|Section|Assessments |R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4|
-{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Assessment|R||}}
+|Section|Functional Status Assessments|O|1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1|Record of assessments of patient's functional status
-{{CDA Document Content| |Medications Administered|R| |}}
+|Section|Procedures and Interventions|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.11|This section is used to record interventions or nursing procedures performed
-{{CDA Document Content| |Intravenous Fluids Administered|R| |}}
+|Section|Medications Administered|R2|1.3.6.1.4.1.19376.1.5.3.1.3.21|
-{{CDA Document Content| |Procedures Performed|R| |}}
+|Section|IV Fluids Administered|R2|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6|
-{{CDA Document Content| |Test Results: Lab, ECG, Radiology|R| |}}
+|Section|ED Disposition|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10|The ED Disposition shall have a Mode of Transport entry describing how the patient departed.
-{{CDA Document Content| |Consultations|R| |}}
-{{CDA Document Content| |Progress Note|R| |}}
-{{CDA Document Content| |ED Diagnoses|R| |}}
-{{CDA Document Content| |ED Disposition|R| |}}
 }}

1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3: Difference between revisions

Latest revision as of 11:13, 2 May 2009

Contents

Development Only

Composite Triage and Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3

Format Code

Parent Template

LOINC Code

Data Element Index

Specification

Conformance

Schematron

Navigation menu

1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3: Difference between revisions

Latest revision as of 11:13, 2 May 2009

Development Only

Composite Triage and Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3

Format Code

Parent Template

LOINC Code

Data Element Index

Specification

Conformance

Schematron

Navigation menu

Search