1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1
Development Only
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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 arrival data, historical information about the patient, vital signs, assessments, and interventions.
LOINC Code
The LOINC code for this document is X-TRIAGE TriageNote
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 | 48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS |
Acuity Assessment | 11283-9 ACUITY ASSESSMENT |
Vital Signs | 8716-3 VITAL SIGNS |
Triage Assessments | XASSES-X NURSING ASSESSMENTS PANEL |
Triage Interventions | NURIN-T NURSING INTERVENTIONS PANEL |
Medications Administered | 18610-6 MEDICATION ADMINISTERED (COMPOSITE) |
Intravenous Fluids Administered | XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE) |
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 | R2 | 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 This section should contain one entry containing the date (TS) of last menstrual period for women of childbearing age, using LOINC Code 8665-2 DATE LAST MENSTRUAL PERIOD |
R2 | 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 |
Nursing Assessments | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 |
Nursing Interventions | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 |
Medications Administered | R2 | 1.3.6.1.4.1.19376.1.5.3.1.3.21 |
Intravenous Fluids Administered | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 |
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='X-TRIAGE' displayName='TriageNote' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Triage Note</title> <effectiveTime value='20240424012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/> : <component><structuredBody> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/> <!-- Required Chief Complaint Section content --> </section> </component> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:ClinicalDocument'> Error: The Triage Note can only be used on Clinical Documents. </assert> <!-- Verify the document type code --> <assert test='cda:code[@code = "X-TRIAGE"]'> Error: The document type code of a Triage Note must be X-TRIAGE </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> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> <!-- Verify that all required data elements are present --> Error: The Triage Note Document must contain a(n) Chief Complaint Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2"]'> <!-- Verify that all required data elements are present --> Error: The Triage Note Document must contain a(n) Mode of Arrival Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> <!-- Verify that all required data elements are present --> Error: The Triage Note Document must contain a(n) History of Present Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Active Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Resolved Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) List of Surgeries Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Immunizations Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.14"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Family History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Social History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) History of Pregnancies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> <!-- Verify that all required data elements are present --> Error: The Triage Note Document must contain a(n) Current Medications Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> <!-- Verify that all required data elements are present --> Error: The Triage Note Document must contain a(n) Allergies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2"]'> <!-- Verify that all required data elements are present --> Error: The Triage Note Document must contain a(n) Acuity Assessment Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2"]'> <!-- Verify that all required data elements are present --> Error: The Triage Note Document must contain a(n) Vital Signs Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Nursing Assessments Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Nursing Interventions Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.21"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Medications Administered Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6"]'> <!-- Alert on any missing required if known elements --> Warning: The Triage Note Document should contain a(n) Intravenous Fluids Administered Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.1 </assert> </rule> </pattern>
Sections
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2
1.3.6.1.4.1.19376.1.5.3.1.3.4
1.3.6.1.4.1.19376.1.5.3.1.3.6
1.3.6.1.4.1.19376.1.5.3.1.3.8
1.3.6.1.4.1.19376.1.5.3.1.3.11
1.3.6.1.4.1.19376.1.5.3.1.3.23
1.3.6.1.4.1.19376.1.5.3.1.3.14
1.3.6.1.4.1.19376.1.5.3.1.3.16
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
1.3.6.1.4.1.19376.1.5.3.1.3.19
1.3.6.1.4.1.19376.1.5.3.1.3.13
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2
1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.9
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.7
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.10
1.3.6.1.4.1.19376.1.5.3.1.3.21
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