|
|
| 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|Comment| |
| 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 Nursing Note specification may be employed where the ED triage note and nNursing notes exist as a single document type |
| | |
| |
| |
| Index={{T|Data Element|LOINC|Rows=
| |
| {{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|Current Medications|10160-0 CURRENT MEDICATIONS|}}
| |
| {{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|Social History|29762-2 SOCIAL HISTORY|}}
| |
| {{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES|}}
| |
| {{R|LMP|8665-2 DATE LAST MENSTRUAL PERIOD|}}
| |
| {{R|Pertinent ROS|10187-3 REVIEW OF SYSTEMS|}}
| |
| {{R|Vital Signs||}}
| |
| {{R|Physical Examination|22029-3 PHYSICAL EXAM.TOTAL|}}
| |
| {{R|Assessment|X-AAPLN ASSESSMENT AND PLAN|}}
| |
| {{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)|}}
| |
| {{R|Intravenous Fluids Administered||}}
| |
| {{R|Procedures Performed|XXXXX-X PROCEDURE PERFORMED|}}
| |
| {{R|Test Results: Lab, ECG, Radiology|30954-2 STUDIES SUMMARY|}}
| |
| {{R|Consultations|11488-4 CONSULTATION NOTE {SETTING} ATTACH.CLINRPT|}}
| |
| {{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 ???|}}
| |
| {{R|Advanced Directives|42348-3 ADVANCE DIRECTIVES|}}
| |
| | |
| }}
| |
| |Data=
| |
| {{CDA Document Content| |Referral Source|R| |}}
| |
| {{CDA Document Content| |Mode of Arrival|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2|}}
| |
| {{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|}}
| |
| {{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|}}
| |
| {{CDA Document Content| |Active Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|}}
| |
| {{CDA Document Content| |Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|}}
| |
| {{CDA Document Content| |Alergies|R| |}}
| |
| {{CDA Document Content| |List of Surgeries|R|1.3.6.1.4.1.19376.1.5.3.1.3.11|}}
| |
| {{CDA Document Content| |Immunizations|R|1.3.6.1.4.1.19376.1.5.3.1.3.23|}}
| |
| {{CDA Document Content| |Family History|R|1.3.6.1.4.1.19376.1.5.3.1.3.14|}}
| |
| {{CDA Document Content| |Social History|R|1.3.6.1.4.1.19376.1.5.3.1.3.16|}}
| |
| {{CDA Document Content| |History of Pregnancies|R| |}}
| |
| {{CDA Document Content| |LMP|R| |}}
| |
| {{CDA Document Content| |Pertinent ROS|R|1.3.6.1.4.1.19376.1.5.3.1.3.18|}}
| |
| {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Vital Signs|R||}}
| |
| {{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|}}
| |
| {{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1|Assessment|R||}}
| |
| {{CDA Document Content| |Medications Administered|R| |}}
| |
| {{CDA Document Content| |Intravenous Fluids Administered|R| |}}
| |
| {{CDA Document Content| |Procedures Performed|R| |}}
| |
| {{CDA Document Content| |Test Results: Lab, ECG, Radiology|R| |}}
| |
| {{CDA Document Content| |Consultations|R| |}}
| |
| {{CDA Document Content| |Progress Note|R| |}}
| |
| {{CDA Document Content| |ED Diagnoses|R| |}}
| |
| {{CDA Document Content| |ED Disposition|R| |}}
| |
| {{CDA Document Content| |(Admission) Inpatient Facility|C| |}}
| |
| {{CDA Document Content| |(Admission) Inpatient Practitioner|C| |}}
| |
| {{CDA Document Content| |(Discharge) Discharge Medications|C| |}}
| |
| {{CDA Document Content| |(Discharge) Discharge Instructions|C| |}}
| |
| {{CDA Document Content| |(Discharge) Referral at ED Disposition|C| |}}
| |
| {{CDA Document Content| |(Discharge) ED Referral Practitioner|C| |}}
| |
| {{CDA Document Content| |(Transfer) Facility Receiving ED Patient|C| |}}
| |
| {{CDA Document Content| |(Transfer) Accepting Practitioner|C| |}}
| |
| {{CDA Document Content| |Advanced Directives|R|1.3.6.1.4.1.19376.1.5.3.1.3.34|}}
| |
| }}
| |
{{CDA Document|Composite Triage and Nursing Note|1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3|Comment|
The Composite Triage and Nursing Note specification may be employed where the ED triage note and nNursing notes exist as a single document type