1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3

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Composite Triage and Nursing Note Specification 1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3

The Composite Triage and Nursing Note specification may be employed where the ED triage note and nursing notes exist as a single document type.

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
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
Level of Consciousness
Pain Scale Assessment	38212-7 Pain assessment panel
Interventions	29554-3 Procedure
Medications Administered	18610-6 MEDICATION ADMINISTERED (COMPOSITE)
Intravenous Fluids Administered
ED Disposition	11302-7 ED DISPOSITION

-->>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	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
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
Level of Consciousness	O	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
Pain Scale Assessment	O	1.3.6.1.4.1.19376.1.5.3.1.1.12.2.1
Interventions Record the interventions performed	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
Medications Administered	R
Intravenous Fluids Administered	R
Procedures Performed	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.

Sample Composite Triage and Nursing 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>Composite Triage and Nursing 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 Composite Triage and Nursing 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>

-->>Clean this up to same as other notes<<--