1.3.6.1.4.1.19376.1.5.3.1.1.13.1.4

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ED Physician Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3

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.

Data Element Index

Data Element	LOINC
Referral Source	11293-8 ED REFERRAL SOURCE
Mode of Arrival	11459-5 TRANSPORT MODE
Chief Complaint	10154-3 CHIEF COMPLAINT FIND
History of Present Illness	10164-2 HISTORY OF PRESENT ILLNESS
Active Problems	10160-0 HISTORY OF MEDICATION USE
Current Medications	10160-0 CURRENT MEDICATIONS
Allergies	X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS
List of Surgeries	10167-5 HISTORY OF SURGICAL PROCEDURES
Immunizations	11369-6 HISTORY OF IMMUNIZATIONS
Family History	10157-6 HISTORY OF FAMILY MEMBER DISEASES
Social History	29762-2 SOCIAL HISTORY
History of Pregnancies	10162-6 HISTORY OF PREGNANCIES
LMP	8665-2 DATE LAST MENSTRUAL PERIOD
Pertinent ROS	10187-3 REVIEW OF SYSTEMS
Vital Signs
Physical Examination	22029-3 PHYSICAL EXAM.TOTAL
Assessment	X-AAPLN ASSESSMENT AND PLAN
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered
Procedures Performed	XXXXX-X PROCEDURE PERFORMED
Test Results: Lab, ECG, Radiology	30954-2 STUDIES SUMMARY
Consultations	11488-4 CONSULTATION NOTE {SETTING} ATTACH.CLINRPT
Progress Note	18733-6 SUBSEQUENT EVALUATION NOTE (ATTENDING PHYSICIAN)
ED Diagnoses	11301-9 ED DIAGNOSIS
ED Disposition	11302-7 ED DISPOSITION
(Admission) Inpatient Facility	LOINC???
(Admission) Inpatient Practitioner	18774-0 STAFF PRACTITIONER NAME ???
(Discharge) Discharge Medications	18617-1 MEDICATION DISCHARGE ???
(Discharge) Discharge Instructions	8653-8 HOSPITAL DISCHARGE INSTRUCTIONS ???
(Discharge) Referral at ED Disposition	11303-5 ED DISPOSITION CONSULT/REFERRAL
(Discharge) ED Referral Practitioner	39266-2 FOLLOW-UP (REFERRED TO) PROVIDER/SPECIALIST
(Transfer) Facility Receiving ED Patient	11453-8 RECEIVING FACILITY
(Transfer) Accepting Practitioner	11303-5 ED DISPOSITION CONSULT/REFERRAL ???
Advanced Directives	42348-3 ADVANCE DIRECTIVES

-->>Data<<--

Specification

Data Element Name	Opt	Template ID
Referral Source	R
Mode of Arrival	R	1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
Chief Complaint	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
History of Present Illness	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems	R	1.3.6.1.4.1.19376.1.5.3.1.3.6
Current Medications	R	1.3.6.1.4.1.19376.1.5.3.1.3.19
Alergies	R
List of Surgeries	R	1.3.6.1.4.1.19376.1.5.3.1.3.11
Immunizations	R	1.3.6.1.4.1.19376.1.5.3.1.3.23
Family History	R	1.3.6.1.4.1.19376.1.5.3.1.3.14
Social History	R	1.3.6.1.4.1.19376.1.5.3.1.3.16
History of Pregnancies	R
LMP	R
Pertinent ROS	R	1.3.6.1.4.1.19376.1.5.3.1.3.18
Vital Signs	R
Physical Examination	R	1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Assessment	R
Medications Administered	R
Intravenous Fluids Administered	R
Procedures Performed	R
Test Results: Lab, ECG, Radiology	R
Consultations	R
Progress Note	R
ED Diagnoses	R
ED Disposition	R
(Admission) Inpatient Facility	C
(Admission) Inpatient Practitioner	C
(Discharge) Discharge Medications	C
(Discharge) Discharge Instructions	C
(Discharge) Referral at ED Disposition	C
(Discharge) ED Referral Practitioner	C
(Transfer) Facility Receiving ED Patient	C
(Transfer) Accepting Practitioner	C
Advanced Directives	R	1.3.6.1.4.1.19376.1.5.3.1.3.34

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.

Sample ED Physician Note Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>ED Physician 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>     </structuredBody></component> </ClinicalDocument>

 

   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a ED Physician Note must be {{{LOINC}}}
   </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>