1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1

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Triage Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1

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Data Element Index

Data Element	LOINC
Chief Complaint	10154-3 CHIEF COMPLAINT
Mode of Arrival	11459-5 TRANSPORT MODE
History of Present Illness	10164-2 HISTORY OF PRESENT ILLNESS
Active Problems - may need PMH LOINC
Current Medications
Allergies
Acuity Assessment	11283-9 ACUITY ASSESSMENT
Vital Signs
Assessments

-->>Data<<--

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
Mode of Arrival	R
History of Present Illness	R	1.3.6.1.4.1.19376.1.5.3.1.3.4
Active Problems - may need PMH LOINC	R
Current Medications	R	1.3.6.1.4.1.19376.1.5.3.1.4.7
Allergies	R
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	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3

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 Triage Note Document

<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1'/> <id root=' ' extension=' '/> <code code=' ' displayName=' ' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Triage 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 Triage 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>