Version 2.76

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|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38952-4 Nurse|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Triage + nota de cuidado:Tipo:Punto temporal:Departamento de Emergencia:Documento:Nurse
it-IT Italian (Italy) Triage e infermieristica, nota:Osservazione:Pt:Pronto Soccorso:Doc:Infermiere
Synonyms: Documentazione dell''ontologia Nota di triage e di infermieristica Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verslag triage en zorg:bevinding:moment:spoedeisende hulp:document:verpleegkundige
Synonyms: SEH
zh-CN Chinese (China) 分诊与护理记录:发现:时间点:急诊科:文档型:护士
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 保护者 分诊(伤病员鉴别分类、治疗类选法、治疗类选、类选、分选、伤检、检伤、检伤分类、分类、分类后送、分伤)与护理记录;分诊与护理学记录;分拣与护理记录;伤病员鉴别分类与护理记录;治疗类选与护理记录;伤检与护理记录;病情评估分流与护理记录;伤检分类与护理记录 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 急诊;急诊部门;急诊部;急诊室;急症科;急诊科室;急救部门 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 笔记;按语;注释;说明;票据;单据;证明书

LOINC Terminology Service (API) using HL7® FHIR® Get Info

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