LOINC
Version 2.71

57054-9Nurse Emergency department Triage+care noteActive

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

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

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
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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.
Order vs. Observation
Both

Reference Information

Type Source Reference
Webcontent Integrating the Healthcare EnterpriseCopyright Copyright © 2009 IHE International.

Member of these Groups

LG41825-7 Emergency department|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38952-4 Nurse|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
分诊与护理记录:发现:时间点:急诊科:文档型:护士
nl-NLDutch (Netherlands)
verslag triage en zorg:bevinding:moment:spoedeisende hulp:document:verpleegkundige
it-ITItalian (Italy)
Triage e infermieristica, nota:Osservazione:Pt:Pronto Soccorso:Doc:Infermiere

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=57054-9