LOINC
Version 2.73

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
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

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
es-MXSpanish (Mexico)
Triage + nota de cuidado:Tipo:Punto temporal:Departamento de Emergencia:Documento:Nurse

LOINC FHIR® API Example - CodeSystem Request Get Info

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