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

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
Current Medications	10160-0 CURRENT MEDICATIONS
Allergies	X-AARA ALLERGIES, ADVERSE REACTIONS, ALERTS
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	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
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	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='20240504012005'/> <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>