1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
Jump to navigation
Jump to search
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
Triage Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
The triage note specification includes sections for data commonly captured during the initial triage assessment of the patient. It includes historical information about the patient, vital signs, and assessments.
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 | 11450-4 PROBLEM LIST |
Resolved Problems | 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 |
LMP | 8665-2 DATE LAST MENSTRUAL PERIOD |
Current Medications | 10160-0 CURRENT MEDICATIONS |
Allergies | X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS |
Acuity Assessment | 11283-9 ACUITY ASSESSMENT |
Vital Signs | 8716-3 VITAL SIGNS |
Assessments |
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 | 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 |
Active Problems | R | 1.3.6.1.4.1.19376.1.5.3.1.3.6 |
Resolved Problems | 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 | R | 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 |
LMP | R | |
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 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3 |
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.
<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='20241017012005'/> <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>
Categories:
- Pages needing work
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.4
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.6
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.8
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.11
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.23
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.14
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.16
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
- Templates using
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.19
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.13
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
- Templates using 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.3
- CDA Document Templates