57054-9
Nurse Emergency department Triage+care note
Active
Term Description
The Composite Triage and ED Nursing Note specification may be employed where the ED Triage Note and ED Nursing Notes exist within a single document. The elements included in the profile are a composite of the elements from the Triage Note specification and the ED Nursing Note specification.
Source: Regenstrief LOINC
Reference Information
| Type | Source | Reference |
|---|---|---|
| Webcontent | Integrating the Healthcare EnterpriseCopyright Copyright © 2009 IHE International. |
Fully-Specified Name
- Component
- Triage+Care note
- Property
- Find
- Time
- Pt
- System
- Emergency department
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse ED Triage+care note
Associated Observations
81898-9 Composite triage and nursing note - recommended IHE set
The recommended set of terms for the IHE Composite triage and nursing note (CTNN) profile document [LOINC: 57054-9].
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81898-9 | Composite triage and nursing note - recommended IHE set | |||
| Indent10154-3 | Chief complaint | |||
| Indent29299-5 | Reason for visit | |||
| Indent11459-5 | Mode of arrival | |||
| Indent10164-2 | History of present illness | |||
| Indent11348-0 | History of past illness | |||
| Indent10167-5 | List of Surgeries | |||
| Indent11369-6 | Immunizations | |||
| Indent10157-6 | Family history | |||
| Indent29762-2 | Social history | |||
| Indent10162-6 | History of pregnancies | |||
| Indent10160-0 | Current medications | |||
| Indent48765-2 | Allergies | |||
| Indent11283-9 | Acuity assessment | |||
| Indent8716-3 | Vital signs | |||
| Indent51848-0 | Assessments | |||
| Indent47420-5 | Functional status assessments | |||
| Indent47519-4 | Procedures and interventions | |||
| Indent18610-6 | Medications administered | |||
| Indent57072-1 | Intravenous fluids administered | |||
| Indent11302-7 | ED disposition |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.29
- Last Updated
- Version 2.67
- Change Reason
- Previous Releases: Edits based on Clinical LOINC Committee review (2/12/2012) of description/use-case for this term. Component was changed from 'Triage and nursing note' to 'Triage+care not', setting was changed to Emergency department, and provider was changed to Nursing.;
- Order vs. Observation
- Both
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41825-7 | Emergency department| |
| LG38952-4 | Nurse| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Triage + nota de cuidado: |
| it-IT | Italian (Italy) | Triage e infermieristica, nota: Synonyms: Documentazione dell''ontologia Nota di triage e di infermieristica Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag triage en zorg: Synonyms: SEH |
| zh-CN | Chinese (China) | 分诊与护理记录: Synonyms: 临床文档型; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=57054-9
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright