1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
Development Only
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ED Physician Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3
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Data Element Index
| Data Element | LOINC |
|---|---|
| Referral Source | |
| Mode of Arrival | |
| Chief Complaint | |
| History of Present Illness | |
| Active Problems | |
| Current Medications | |
| Alergies | |
| List of Surgeries | |
| Immunizations | |
| Family History | |
| Social History | |
| History of Pregnancies | |
| LMP | |
| Pertinent ROS | |
| Vital Signs | |
| Physical Examination | |
| Assessment | |
| Medications Administered | |
| Intravenous Fluids Administered | |
| Procedures Performed | |
| Test Results: Lab, ECG, Radiology | |
| Consultations | |
| Progress Note | |
| ED Diagnoses | |
| ED Disposition |
-->>Data<<--
Specification
| Data Element Name | Opt | Template ID |
|---|---|---|
| Referral Source | R | |
| Mode of Arrival | R | |
| Chief Complaint | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 |
| History of Present Illness | R | |
| Active Problems | R | |
| Current Medications | R | |
| Alergies | R | |
| List of Surgeries | R | |
| Immunizations | R | |
| Family History | R | |
| Social History | R | |
| History of Pregnancies | R | |
| LMP | R | |
| Pertinent ROS | R | |
| 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 |
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.
<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>