Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3"
Line 14: | Line 14: | ||
{{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES}} | {{R|History of Pregnancies|10162-6 HISTORY OF PREGNANCIES}} | ||
{{R|Current Medications|10160-0 CURRENT MEDICATIONS|}} | {{R|Current Medications|10160-0 CURRENT MEDICATIONS|}} | ||
− | {{R|Allergies| | + | {{R|Allergies|48765-2 ALLERGIES, ADVERSE REACTIONS, ALERTS|}} |
{{R|Acuity Assessment|11283-9 ACUITY ASSESSMENT|}} | {{R|Acuity Assessment|11283-9 ACUITY ASSESSMENT|}} | ||
{{R|Vital Signs|8716-3 VITAL SIGNS|}} | {{R|Vital Signs|8716-3 VITAL SIGNS|}} | ||
− | {{R|Assessments | + | {{R|Nursing Assessments |XASSES-X|}} |
− | {{R|Interventions | + | {{R|Nursing Interventions |NURIN-T NURSING INTERVENTIONS}} |
{{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)}} | {{R|Medications Administered|18610-6 MEDICATION ADMINISTERED (COMPOSITE)}} | ||
{{R|Intravenous Fluids Administered|XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)}} | {{R|Intravenous Fluids Administered|XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE)}} | ||
Line 27: | Line 27: | ||
|Section|Mode of Arrival|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2| | |Section|Mode of Arrival|R|1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2| | ||
|Section|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4| | |Section|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4| | ||
− | |Section|Active Problems| | + | |Section|Active Problems|R2|1.3.6.1.4.1.19376.1.5.3.1.3.6| |
|Section|Resolved Problems|R2|1.3.6.1.4.1.19376.1.5.3.1.3.8| | |Section|Resolved Problems|R2|1.3.6.1.4.1.19376.1.5.3.1.3.8| | ||
|Section|List of Surgeries|R2|1.3.6.1.4.1.19376.1.5.3.1.3.11| | |Section|List of Surgeries|R2|1.3.6.1.4.1.19376.1.5.3.1.3.11| | ||
Line 33: | Line 33: | ||
|Section|Family History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.14| | |Section|Family History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.14| | ||
|Section|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16| | |Section|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16| | ||
− | |Section|History of Pregnancies| | + | |Section|History of Pregnancies|R2|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|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 |
|Section|Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19| | |Section|Current Medications|R|1.3.6.1.4.1.19376.1.5.3.1.3.19| | ||
|Section|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13| | |Section|Allergies|R|1.3.6.1.4.1.19376.1.5.3.1.3.13| | ||
Line 46: | Line 46: | ||
==Sections== | ==Sections== | ||
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.10.3.2]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.4]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.4]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.6]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.6]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.8]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.8]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.11]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.11]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.23]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.23]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.14]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.14]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.16]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.16]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.19]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.19]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.13]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.13]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.2]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.5.3.2]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.3.21]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.3.21]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6]]<br/> |
− | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8]] | + | [[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8]]<br/> |
{{Fixme|Clean this up to same as other notes}} | {{Fixme|Clean this up to same as other notes}} |
Revision as of 10:48, 2 June 2007
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
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 within a single document. The elements below are an exact composite of the elements from the Triage Note specification and the Nursing Note specification.
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 |
Nursing Assessments | XASSES-X |
Nursing Interventions | NURIN-T NURSING INTERVENTIONS |
Medications Administered | 18610-6 MEDICATION ADMINISTERED (COMPOSITE) |
Intravenous Fluids Administered | XIVFLU-X INTRAVENOUS FLUID ADMINISTERED (COMPOSITE) |
ED Disposition | 11302-7 ED DISPOSITION |
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 Battery | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.4 |
Nursing Interventions Battery | 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 |
IV Fluids Administered | R2 | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6 |
ED Disposition | R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8 |
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='X-TRIAGE' displayName='TriageNote' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Composite Triage and Nursing Note</title> <effectiveTime value='20240505012005'/> <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_1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:ClinicalDocument'> Error: The Composite Triage and Nursing 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 Composite Triage and Nursing 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 Composite Triage and Nursing Note Document must contain a(n) Chief Complaint Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document must contain a(n) Mode of Arrival Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document must contain a(n) History of Present Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) Active Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) Resolved Problems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) List of Surgeries Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) Immunizations Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) Family History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) Social History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) History of Pregnancies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document must contain a(n) Current Medications Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document must contain a(n) Allergies Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document must contain a(n) Acuity Assessment Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document must contain a(n) Vital Signs Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) Nursing Assessments Battery Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) Nursing Interventions Battery Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) Medications Administered Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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 Composite Triage and Nursing Note Document should contain a(n) IV Fluids Administered Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8"]'> <!-- Verify that all required data elements are present --> Error: The Composite Triage and Nursing Note Document must contain a(n) ED Disposition Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.13.1.3 </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
1.3.6.1.4.1.19376.1.5.3.1.3.21
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.6
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.8
- 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
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- Templates using 1.3.6.1.4.1.19376.1.5.3.1.3.14
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- 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
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