74198-3
Trauma Summary registry report
Active
Term Description
A trauma case described in a uniform set of data elements, including injury, pre-hospital care, and hospital care.
Source: Regenstrief LOINC
Fully-Specified Name
- Component
- Summary registry report
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Trauma
Additional Names
- Short Name
- Trauma Summary registry report
Associated Observations
87825-6 National Trauma Data Standard - version 2018 set
This panel contains the set of LOINC codes used in the 2018 National Trauma Data Standard data dictionary, which is used as a national standard in the United States for the exchange of trauma registry data.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 87825-6 | National Trauma Data Standard - version 2018 set | |||
| Indent74283-3 | Alternate home residence | |||
| Indent30525-0 | Age | a | ||
| Indent74291-6 | Co-morbid conditions | |||
| Indent52797-8 | ICD-10 injury diagnoses | |||
| Indent76067-8 | Abbreviated Injury Scale panel AAAM | |||
| Indent Indent76066-0 | AIS version | R | ||
| Indent Indent75890-4 | AIS predot code | O | ||
| Indent Indent75891-2 | AIS severity | R | {score} | |
| Indent74202-3 | Primary method of payment | |||
| Indent67554-6 | Work related exposure, injury, or death? | |||
| Indent85078-4 | Occupation industry [Type] | |||
| Indent85658-3 | Occupation [Type] | |||
| Indent69543-7 | ICD-10 primary external cause code | |||
| Indent74496-1 | Injury location ICD code | |||
| Indent74292-4 | ICD-10 additional external cause code | |||
| Indent67499-4 | Protective devices | |||
| Indent67499-4 | Child specific restraint | |||
| Indent67500-9 | Indication of Airbag deployment during the motor vehicle crash | |||
| Indent87517-9 | Report of physical abuse | |||
| Indent87519-5 | Investigation of physical abuse | |||
| Indent87518-7 | Caregiver at discharge | |||
| Indent74200-7 | Total ICU length of stay | d | ||
| Indent74201-5 | Total ventilator days | d | ||
| Indent74290-8 | Hospital discharge disposition [NTDS] | |||
| Indent69471-1 | EMS dispatch date | |||
| Indent69471-1 | EMS dispatch time | |||
| Indent69473-7 | EMS unit arrival date at scene or transferring facility | |||
| Indent69473-7 | EMS unit arrival time at scene or transferring facility | |||
| Indent69475-2 | EMS unit departure date from scene or transferring facility | |||
| Indent69475-2 | EMS unit departure time from scene or transferring facility | |||
| Indent74286-6 | Transport mode | |||
| Indent74286-6 | Other transport mode | |||
| Indent8480-6 | Initial field systolic blood pressure | mm[Hg] | ||
| Indent8867-4 | Initial field pulse rate | {beats}/min;{counts/min} | ||
| Indent9279-1 | Initial field respiratory rate | {breaths}/min;{counts/min} | ||
| Indent2708-6 | Initial field oxygen saturation | % | ||
| Indent9267-6 | Initial field GCS - Eye | |||
| Indent9270-0 | Initial field GCS - Verbal | |||
| Indent9268-4 | Initial field GCS - Motor | |||
| Indent9269-2 | Initial field GCS - Total | {score} | ||
| Indent74199-1 | Inter-facility transfer | |||
| Indent67495-2 | Trauma center criteria | |||
| Indent67496-0 | Vehicular, pedestrian, other risk injury | |||
| Indent8480-6 | Initial ED/Hospital systolic blood pressure | mm[Hg] | ||
| Indent8867-4 | Initial ED/Hospital pulse rate | {beats}/min;{counts/min} | ||
| Indent8310-5 | Initial ED/Hospital temperature | Cel | ||
| Indent9279-1 | Initial ED/Hospital respiratory rate | {breaths}/min;{counts/min} | ||
| Indent74210-6 | Initial ED/Hospital respiratory assistance | |||
| Indent2708-6 | Initial ED/Hospital oxygen saturation | % | ||
| Indent74206-4 | Initial ED/Hospital supplemental oxygen | |||
| Indent9267-6 | Initial ED/Hospital GCS - Eye | |||
| Indent9270-0 | Initial ED/Hospital GCS - verbal | |||
| Indent9268-4 | Initial ED/Hospital GCS - motor | |||
| Indent9269-2 | Initial ED/Hospital GCS - total | {score} | ||
| Indent55285-1 | Initial ED/Hospital GCS assessment qualifiers | |||
| Indent8302-2 | Initial ED/Hospital height | [in_us];cm;m | ||
| Indent29463-7 | Initial ED/Hospital weight | [lb_av];kg | ||
| Indent34601-5 | Drug screen | |||
| Indent5640-8 | Alcohol screen | mg/dL | ||
| Indent11302-7 | ED discharge disposition | |||
| Indent74203-1 | Signs of life | |||
| Indent9269-2 | Highest GCS Total | {score} | ||
| Indent9268-4 | Highest GCS Motor | |||
| Indent55285-1 | GCS qualifier component of highest GCS total | |||
| Indent87515-3 | Initial ED/Hospital pupillary response | |||
| Indent87514-6 | Cerebral monitor | |||
| Indent1298-9 | Packed erythrocytes given [Volume] | mL | ||
| Indent10411-7 | Plasma given [Volume] | mL | ||
| Indent1299-7 | Platelets given [Volume] | mL | ||
| Indent10392-9 | Cryoprecipitate given [Volume] | mL | ||
| Indent8480-6 | Lowest ED/Hospital systolic blood pressure | mm[Hg] | ||
| Indent87516-1 | Withdrawal of life support treatment | |||
| Indent74284-1 | Hospital complications |
84428-2 National EMS Information System - version 3 set
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 84428-2 | National EMS Information System - version 3 set | |||
| Indent67660-1 | EMS dispatch Narrative NEMSIS | |||
| Indent67570-2 | The complaint dispatch reported to the responding unit. | |||
| Indent67488-7 | Indication of whether Emergency Medical Dispatch was performed for this EMS event | |||
| Indent71580-5 | Crew member level | |||
| Indent71581-3 | Crew member response role NEMSIS | |||
| Indent67664-3 | EMS response Narrative NEMSIS | |||
| Indent71583-9 | Service requested of EMS unit | |||
| Indent71579-7 | Unit transport and equipment capability EMS unit | |||
| Indent67480-4 | The dispatch delays, if any, associated with the dispatch of the EMS unit to the patient encounter | |||
| Indent67557-9 | The response delays, if any, of the unit associated with the patient encounter | |||
| Indent67558-7 | The scene delays, if any, of the unit associated with the patient encounter | |||
| Indent67559-5 | The transport delays, if any, of the unit associated with the patient encounter | |||
| Indent67560-3 | The turn-around delays, if any, associated with the EMS unit associated with the patient encounter | |||
| Indent69466-1 | The EMS Location or healthcare facility name representing the geographic location of the vehicle at the time of dispatch. | |||
| Indent69465-3 | The GPS coordinates associated with the EMS unit at the time of dispatch documented in decimal degrees. | deg | ||
| Indent69750-8 | EMS unit GPS latitude Vehicle --at dispatch | |||
| Indent67484-6 | The mileage (counter or odometer reading) of the vehicle at the beginning of the call (when the wheels begin moving). | [mi_us] | ||
| Indent67485-3 | The mileage (counter or odometer reading) of the vehicle when it arrives at the patient | [mi_us] | ||
| Indent67486-1 | The mileage (counter or odometer reading) of the vehicle when it arrives at the patient's destination | [mi_us] | ||
| Indent67487-9 | The ending mileage (counter or odometer reading) of the vehicle (at time back in service) | [mi_us] | ||
| Indent67482-0 | The indication whether the response was emergent or non-emergent. An emergent response is an immediate response. | |||
| Indent77157-6 | EMS Response mode descriptors NEMSIS | |||
| Indent67667-6 | EMS times Narrative NEMSIS | |||
| Indent69469-5 | 911 call to public safety answering point or other designated entity requesting EMS services [Date and time] Facility | |||
| Indent69470-3 | Dispatch was notified by the 911 call taker [Date and time] Facility | |||
| Indent69471-1 | Responding unit was notified by dispatch [Date and time] Vehicle | |||
| Indent69472-9 | Unit responded [Date and time] Vehicle | |||
| Indent69473-7 | Responding unit arrived on the scene [Date and time] Vehicle | |||
| Indent69474-5 | Responding unit arrived at the patient's side [Date and time] Vehicle | |||
| Indent69475-2 | Responding unit left the scene with a patient [Date and time] Vehicle | |||
| Indent69476-0 | Responding unit arrived with the patient at the destination or transfer point [Date and time] Vehicle | |||
| Indent69477-8 | Unit was back in service and available for response [Date and time] Vehicle | |||
| Indent67659-3 | EMS billing Narrative NEMSIS | |||
| Indent69464-6 | The CMS service level for this EMS encounter. | |||
| Indent67556-1 | The condition codes are used to better describe the service and patient care delivery by an EMS service. | |||
| Indent67665-0 | EMS scene Narrative NEMSIS | |||
| Indent67481-2 | Documentation that this EMS Unit was the first EMS Unit for any EMS Agency on the Scene. | |||
| Indent67489-5 | Indicator of how many total patients were at the scene | |||
| Indent67490-3 | Indicator if this event would be considered a mass casualty incident (overwhelmed existing EMS resources) | |||
| Indent74496-1 | Injury location ICD code | |||
| Indent67666-8 | EMS situation Narrative NEMSIS | |||
| Indent69467-9 | Possible injury | |||
| Indent72114-2 | Complaint type | |||
| Indent10154-3 | Chief complaint Narrative - Reported | |||
| Indent67491-1 | The time duration of the healthcare complaint | min;h;d;mo;a | ||
| Indent71588-8 | Chief complaint anatomic location | |||
| Indent69468-7 | Chief complaint organ system | |||
| Indent67774-0 | The EMS personnel's impression of the patient's primary problem or most significant condition which led to the management given to the patient (treatments, medications, or procedures).IDC-10 code | |||
| Indent67776-5 | Other symptoms identified by the patient or observed by EMS personnel based on the ICD-10 Primary Symptom Code | |||
| Indent67492-9 | The EMS personnel's impression of the patient's primary problem or most significant condition which led to the management given to the patient (treatments, medications, or procedures).IDC-10 code | |||
| Indent69542-9 | Provider's Secondary Impressions | |||
| Indent67493-7 | The condition of the patient on EMS arrival at the scene | |||
| Indent67800-3 | EMS injury incident description Narrative NEMSIS | |||
| Indent69543-7 | Cause of injury NEMSIS | |||
| Indent67494-5 | General mechanism of the forces which caused the injury | |||
| Indent67495-2 | Trauma Triage Criteria (Steps 1 and 2) | |||
| Indent67496-0 | Trauma Triage Criteria (Steps 3 and 4) | |||
| Indent67497-8 | The primary area or location of impact on the vehicle | |||
| Indent67498-6 | The seat row location of the patient in vehicle at the time of the crash | |||
| Indent67499-4 | Safety equipment in use by the patient at the time of the injury - MMUCC P7 data element | |||
| Indent67500-9 | Indication of Airbag deployment during the motor vehicle crash | |||
| Indent67501-7 | The distance in feet the patient fell, measured from the lowest point of the patient to the position of the patient at the end of the fall. | [ft_us] | ||
| Indent67799-7 | EMS cardiac arrest event Narrative NEMSIS | |||
| Indent67502-5 | Indication of the presence of a cardiac arrest at any time associated with the EMS event | |||
| Indent67503-3 | Indication of the etiology or cause of the cardiac arrest (classified as cardiac, non-cardiac, etc.) | |||
| Indent72115-9 | Resuscitation Attempted | |||
| Indent67505-8 | Indication of who the cardiac arrest was witnessed by | |||
| Indent67508-2 | AED Use Prior to EMS Arrival | |||
| Indent67510-8 | CPR technique | |||
| Indent67511-6 | Documentation of EMS initiation of Therapeutic Hypothermia. | |||
| Indent67512-4 | First monitored rhythm | |||
| Indent88670-5 | Return of spontaneous circulation | |||
| Indent67574-4 | Reason CPR resuscitation discontinued | |||
| Indent67514-0 | The patient's cardiac rhythm upon delivery or transfer of care at the destination | |||
| Indent77152-7 | Cardiac arrest event outcome NEMSIS | |||
| Indent88102-9 | Who first initiated CPR | |||
| Indent100034-8 | Who first applied the AED | |||
| Indent88663-0 | Who first defibrillated the patient | |||
| Indent67840-9 | EMS advance directives Narrative NEMSIS | |||
| Indent67515-7 | Indication of whether or not there were any patient specific barriers to serving the patient at the scene | |||
| Indent67516-5 | The presence of a valid form or living will document directing end of life or healthcare treatment decisions | |||
| Indent67841-7 | EMS allergies and adverse reactions Narrative NEMSIS | |||
| Indent67794-8 | Does the patient have any allergies? | |||
| Indent67850-8 | The patient's medication allergies | |||
| Indent69747-4 | Does the patient have any environmental allergies NEMSIS | |||
| Indent79151-7 | Known allergies to food or environmental agents | |||
| Indent67842-5 | EMS past medical history Narrative NEMSIS | |||
| Indent68487-8 | Medical - surgical history - ICD-10 codes | |||
| Indent67793-0 | Has the patient had any significant medical conditions? | |||
| Indent67792-2 | Has the patient had any significant medical procedures? | |||
| Indent67844-1 | EMS current medications Narrative NEMSIS | |||
| Indent67791-4 | Does the patient take any medications? | |||
| Indent67843-3 | EMS social history Narrative NEMSIS | |||
| Indent67669-2 | Indicators for the potential use of alcohol or drugs by the patient. | |||
| Indent69757-3 | Are there any indications of drug or alcohol use by the patient? | |||
| Indent67471-3 | Indication of the possibility by the patient's history of current pregnancy | |||
| Indent67517-3 | Last Oral Intake | |||
| Indent67801-1 | EMS vital signs Narrative NEMSIS | |||
| Indent67518-1 | Obtained Prior to this Units EMS Care | |||
| Indent67519-9 | The cardiac rhythm and other electrocardiography findings associated with the patient | |||
| Indent71575-5 | ECG NEMSIS | |||
| Indent71577-1 | ECG interpretation method NEMSIS | |||
| Indent8480-6 | Systolic blood pressure | mm[Hg] | ||
| Indent8462-4 | Diastolic blood pressure | mm[Hg] | ||
| Indent8867-4 | Heart rate | {beats}/min;{counts/min} | ||
| Indent2708-6 | Oxygen saturation in Arterial blood | % | ||
| Indent9279-1 | Respiratory rate | {breaths}/min;{counts/min} | ||
| Indent19889-5 | Carbon dioxide level | % | ||
| Indent19911-7 | Carbon monoxide level | cm3/min/mm[Hg] | ||
| Indent2339-0 | Blood glucose level | mg/dL | ||
| Indent9267-6 | Glasgow coma score eye opening | |||
| Indent9270-0 | Glasgow coma score verbal | |||
| Indent9268-4 | Glasgow coma score motor | |||
| Indent55285-1 | Glasgow coma score qualifier | |||
| Indent9269-2 | Glasgow coma score total | {score} | ||
| Indent8310-5 | Body temperature | Cel | ||
| Indent67775-7 | Level of responsiveness (AVPU) | |||
| Indent56840-2 | Pain score | {score} | ||
| Indent67520-7 | Stroke scale score | |||
| Indent67521-5 | Stroke Scale Type | |||
| Indent67523-1 | Reperfusion checklist | |||
| Indent67668-4 | EMS physical assessment Narrative NEMSIS | |||
| Indent8335-2 | Body weight Estimated | [lb_av];kg | ||
| Indent67670-0 | The Length - based tape measure as take from the tape | |||
| Indent67524-9 | The assessment of the patient's skin on examination | |||
| Indent67525-6 | The assessment findings associated with the patients head. | |||
| Indent67526-4 | The assessment findings associated with the patients face | |||
| Indent67527-2 | The assessment findings associated with the patients neck. | |||
| Indent67529-8 | The assessment findings associated with the patients heart | |||
| Indent71584-7 | Exam finding location Abdomen NEMSIS | |||
| Indent67530-6 | The assessment findings associated with the patients abdomen. | |||
| Indent67531-4 | The assessment findings associated with the patients pelvic and genitourinary exam | |||
| Indent71589-6 | Exam finding location Back+Spine NEMSIS | |||
| Indent67532-2 | The assessment findings associated with the patient spine (Cervical, Thoracic, Lumbar, and Sacral) and back exam. | |||
| Indent71585-4 | Exam finding location Extremity NEMSIS | |||
| Indent67533-0 | The assessment of the patient's extremities. | |||
| Indent71586-2 | Exam finding location Eye NEMSIS | |||
| Indent67534-8 | The assessment findings of the patient's left eye examination | |||
| Indent67535-5 | The assessment of the patient's mental status on examination | |||
| Indent67536-3 | The assessment of the patient's neurological status on examination | |||
| Indent100036-3 | Exam finding location of Lung | |||
| Indent32449-1 | Physical findings of Lung | |||
| Indent100035-5 | Exam finding location of Chest | |||
| Indent11422-3 | Physical findings of Chest | |||
| Indent67663-5 | EMS protocol Narrative NEMSIS | |||
| Indent67537-1 | The protocol used by EMS personnel to direct the clinical care of the patient | |||
| Indent67538-9 | The age group the protocol is written to address | |||
| Indent67849-0 | EMS medications administered Narrative NEMSIS | |||
| Indent67539-7 | Medication administered prior to this unit's EMS care | |||
| Indent67797-1 | Medication given to the patient | |||
| Indent72113-4 | Medication not given reason | |||
| Indent67540-5 | The patients response to the medication. | |||
| Indent67541-3 | Any complication (abnormal effect on the patient) associated with the administration of the medication to the patient by EMS | |||
| Indent71573-0 | Medication authorization NEMSIS | |||
| Indent67802-9 | EMS procedures Narrative NEMSIS | |||
| Indent67542-1 | Indicates that the procedure which was performed and documented was performed prior to this EMS units care. | |||
| Indent72112-6 | Procedure not performed reason | |||
| Indent67798-9 | Did the encounter team perform any procedures? | |||
| Indent67543-9 | The number of attempts taken to complete a procedure or intervention regardless of success | {#} | ||
| Indent67544-7 | Indication of whether or not the procedure performed on the patient was successful | |||
| Indent67545-4 | Any complication associated with the performance of the procedure on the patient | |||
| Indent67546-2 | The patient response to the procedure | |||
| Indent71582-1 | Person performing procedure NEMSIS | |||
| Indent71587-0 | IV site NEMSIS | |||
| Indent71574-8 | Airway device confirmed for placement | |||
| Indent71576-3 | Airway device placement confirmation method | |||
| Indent67661-9 | EMS disposition Narrative NEMSIS | |||
| Indent67547-0 | The number of patients transported by this EMS crew and unit. | {#} | ||
| Indent67549-6 | The method of transport by EMS | |||
| Indent67550-4 | Indication whether the transport was emergent or non-emergent. | |||
| Indent77153-5 | EMS Transport mode descriptors NEMSIS | |||
| Indent77941-3 | Final patient acuity NEMSIS | |||
| Indent67552-0 | The reason the unit chose to deliver or transfer the patient to the destination | |||
| Indent71578-9 | EMS transport destination NEMSIS | |||
| Indent77154-3 | Hospital inpatient destination | |||
| Indent77155-0 | Hospital designation capability | |||
| Indent69462-0 | Activation of the destination healthcare facility team | |||
| Indent100037-1 | Patient contact disposition EMS unit | |||
| Indent100038-9 | Patient evaluation disposition EMS unit | |||
| Indent100039-7 | Crew disposition for patient care EMS unit | |||
| Indent100040-5 | Patient transport disposition EMS unit | |||
| Indent67658-5 | EMS exposures or injuries of EMS personnel Provider Narrative NEMSIS | |||
| Indent67553-8 | Condition indicating eligibility for illness or injury registry | |||
| Indent67554-6 | Indication of an EMS work related exposure, injury, or death associated with this EMS event. | |||
| Indent67555-3 | The type of exposure or unprotected contact with blood or body fluids | |||
| Indent69463-8 | Event caused by natural forces or Suspected and Intentional/Unintentional Disasters (terrorism). | |||
| Indent67781-5 | The narrative of the patient care report (PCR) |
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
This panel contains the recommended section and entry level LOINCs for an EMS patient care report based on the HL7 Version 3 Implementation Guide for CDA Release 2 - Level 3: Emergency Medical Services; Patient Care Report, Release 1 & 2 - US Realm.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set | |||
| Indent67840-9 | EMS advance directives Narrative NEMSIS | |||
| Indent67516-5 | The presence of a valid form or living will document directing end of life or healthcare treatment decisions | |||
| Indent48765-2 | Allergies and adverse reactions Document | |||
| Indent69747-4 | Does the patient have any environmental allergies NEMSIS | |||
| Indent79151-7 | Known allergies to food or environmental agents | |||
| Indent67794-8 | Does the patient have any allergies? | |||
| Indent67659-3 | EMS billing Narrative NEMSIS | |||
| Indent67556-1 | The condition codes are used to better describe the service and patient care delivery by an EMS service. | |||
| Indent69464-6 | The CMS service level for this EMS encounter. | |||
| Indent67799-7 | EMS cardiac arrest event Narrative NEMSIS | |||
| Indent67503-3 | Indication of the etiology or cause of the cardiac arrest (classified as cardiac, non-cardiac, etc.) | |||
| Indent67508-2 | AED Use Prior to EMS Arrival | |||
| Indent67844-1 | EMS current medications Narrative NEMSIS | |||
| Indent67791-4 | Does the patient take any medications? | |||
| Indent67556-1 | The condition codes are used to better describe the service and patient care delivery by an EMS service. | |||
| Indent69749-0 | Is the patient on anticoagulants NEMSIS | |||
| Indent67660-1 | EMS dispatch Narrative NEMSIS | |||
| Indent67488-7 | Indication of whether Emergency Medical Dispatch was performed for this EMS event | |||
| Indent67547-0 | The number of patients transported by this EMS crew and unit. | {#} | ||
| Indent67570-2 | The complaint dispatch reported to the responding unit. | |||
| Indent67661-9 | EMS disposition Narrative NEMSIS | |||
| Indent67547-0 | The number of patients transported by this EMS crew and unit. | {#} | ||
| Indent67548-8 | Incident - patient disposition | |||
| Indent67550-4 | Indication whether the transport was emergent or non-emergent. | |||
| Indent77153-5 | EMS Transport mode descriptors NEMSIS | |||
| Indent67549-6 | The method of transport by EMS | |||
| Indent67550-4 | Indication whether the transport was emergent or non-emergent. | |||
| Indent77153-5 | EMS Transport mode descriptors NEMSIS | |||
| Indent67800-3 | EMS injury incident description Narrative NEMSIS | |||
| Indent67494-5 | General mechanism of the forces which caused the injury | |||
| Indent67495-2 | CDC field triage criteria NEMSIS | |||
| Indent67496-0 | Other injury risk factors NEMSIS | |||
| Indent67497-8 | The primary area or location of impact on the vehicle | |||
| Indent67498-6 | The seat row location of the patient in vehicle at the time of the crash | |||
| Indent67499-4 | Safety equipment in use by the patient at the time of the injury - MMUCC P7 data element | |||
| Indent67500-9 | Indication of Airbag deployment during the motor vehicle crash | |||
| Indent67501-7 | The distance in feet the patient fell, measured from the lowest point of the patient to the position of the patient at the end of the fall. | [ft_us] | ||
| Indent67849-0 | EMS medications administered Narrative NEMSIS | |||
| Indent67540-5 | The patients response to the medication. | |||
| Indent67541-3 | Any complication (abnormal effect on the patient) associated with the administration of the medication to the patient by EMS | |||
| Indent67539-7 | Medication administered prior to this unit's EMS care | |||
| Indent67842-5 | EMS past medical history Narrative NEMSIS | |||
| Indent67793-0 | Has the patient had any significant medical conditions? | |||
| Indent68487-8 | The patient's pre-existing medical and surgery history of the patient based on either ICD-10 Disease or ICD-10 Procedure Codes. | |||
| Indent67781-5 | The narrative of the patient care report (PCR) | |||
| Indent67658-5 | EMS exposures or injuries of EMS personnel Provider Narrative NEMSIS | |||
| Indent67554-6 | Work related exposure, injury, or death? | |||
| Indent29545-1 | Physical findings Narrative | |||
| Indent67524-9 | The assessment of the patient's skin on examination | |||
| Indent67525-6 | The assessment findings associated with the patients head. | |||
| Indent67536-3 | The assessment of the patient's neurological status on examination | |||
| Indent67526-4 | The assessment findings associated with the patients face | |||
| Indent67527-2 | The assessment findings associated with the patients neck. | |||
| Indent67528-0 | Physical findings of Chest+Lungs | |||
| Indent67529-8 | The assessment findings associated with the patients heart | |||
| Indent67530-6 | The assessment findings associated with the patients abdomen. | |||
| Indent67531-4 | The assessment findings associated with the patients pelvic and genitourinary exam | |||
| Indent67532-2 | The assessment findings associated with the patient spine (Cervical, Thoracic, Lumbar, and Sacral) and back exam. | |||
| Indent67533-0 | The assessment of the patient's extremities. | |||
| Indent67534-8 | The assessment findings of the patient's left eye examination | |||
| Indent67535-5 | The assessment of the patient's mental status on examination | |||
| Indent67471-3 | Indication of the possibility by the patient's history of current pregnancy | |||
| Indent67517-3 | Last Oral Intake | |||
| Indent30525-0 | Age | a | ||
| Indent67523-1 | Reperfusion checklist | |||
| Indent67515-7 | Indication of whether or not there were any patient specific barriers to serving the patient at the scene | |||
| Indent8335-2 | Body weight Estimated | [lb_av];kg | ||
| Indent67670-0 | The Length - based tape measure as take from the tape | |||
| Indent29554-3 | Procedure Narrative | |||
| Indent67542-1 | Indicates that the procedure which was performed and documented was performed prior to this EMS units care. | |||
| Indent67543-9 | The number of attempts taken to complete a procedure or intervention regardless of success | {#} | ||
| Indent67544-7 | Indication of whether or not the procedure performed on the patient was successful | |||
| Indent67545-4 | Any complication associated with the performance of the procedure on the patient | |||
| Indent67546-2 | The patient response to the procedure | |||
| Indent71576-3 | Airway device placement confirmation method | |||
| Indent67504-1 | Indication of reason resuscitation the patient who is in cardiac arrest not attempted | |||
| Indent67663-5 | EMS protocol Narrative NEMSIS | |||
| Indent67537-1 | The protocol used by EMS personnel to direct the clinical care of the patient | |||
| Indent67538-9 | The age group the protocol is written to address | |||
| Indent67553-8 | Condition indicating eligibility for illness or injury registry | |||
| Indent67664-3 | EMS response Narrative NEMSIS | |||
| Indent67480-4 | The dispatch delays, if any, associated with the dispatch of the EMS unit to the patient encounter | |||
| Indent67557-9 | The response delays, if any, of the unit associated with the patient encounter | |||
| Indent67558-7 | The scene delays, if any, of the unit associated with the patient encounter | |||
| Indent67559-5 | The transport delays, if any, of the unit associated with the patient encounter | |||
| Indent67560-3 | The turn-around delays, if any, associated with the EMS unit associated with the patient encounter | |||
| Indent69466-1 | The EMS Location or healthcare facility name representing the geographic location of the vehicle at the time of dispatch. | |||
| Indent52002-3 | Ambulance transport, Destination site latitude coordinate | |||
| Indent52003-1 | Ambulance transport, Destination site longitude coordinate | |||
| Indent67484-6 | The mileage (counter or odometer reading) of the vehicle at the beginning of the call (when the wheels begin moving). | [mi_us] | ||
| Indent67485-3 | The mileage (counter or odometer reading) of the vehicle when it arrives at the patient | [mi_us] | ||
| Indent67486-1 | The mileage (counter or odometer reading) of the vehicle when it arrives at the patient's destination | [mi_us] | ||
| Indent67487-9 | The ending mileage (counter or odometer reading) of the vehicle (at time back in service) | [mi_us] | ||
| Indent67482-0 | The indication whether the response was emergent or non-emergent. An emergent response is an immediate response. | |||
| Indent77157-6 | EMS Response mode descriptors NEMSIS | |||
| Indent77156-8 | EMS unit Level of care capability | |||
| Indent67665-0 | EMS scene Narrative NEMSIS | |||
| Indent67481-2 | Documentation that this EMS Unit was the first EMS Unit for any EMS Agency on the Scene. | |||
| Indent67489-5 | Indicator of how many total patients were at the scene | |||
| Indent67490-3 | Indicator if this event would be considered a mass casualty incident (overwhelmed existing EMS resources) | |||
| Indent67666-8 | EMS situation Narrative NEMSIS | |||
| Indent10154-3 | Chief complaint Narrative - Reported | |||
| Indent69467-9 | Possible injury | |||
| Indent67492-9 | The EMS personnel's impression of the patient's primary problem or most significant condition which led to the management given to the patient (treatments, medications, or procedures).IDC-10 code | |||
| Indent67776-5 | Other symptoms identified by the patient or observed by EMS personnel based on the ICD-10 Primary Symptom Code | |||
| Indent67493-7 | The condition of the patient on EMS arrival at the scene | |||
| Indent69542-9 | Provider's Secondary Impressions | |||
| Indent67843-3 | EMS social history Narrative NEMSIS | |||
| Indent69757-3 | Are there any indications of drug or alcohol use by the patient? | |||
| Indent67669-2 | Indicators for the potential use of alcohol or drugs by the patient. | |||
| Indent67667-6 | EMS times Narrative NEMSIS | |||
| Indent69469-5 | 911 call to public safety answering point or other designated entity requesting EMS services [Date and time] Facility | |||
| Indent69471-1 | Responding unit was notified by dispatch [Date and time] Vehicle | |||
| Indent69472-9 | Unit responded [Date and time] Vehicle | |||
| Indent69473-7 | Responding unit arrived on the scene [Date and time] Vehicle | |||
| Indent69474-5 | Responding unit arrived at the patient's side [Date and time] Vehicle | |||
| Indent69475-2 | Responding unit left the scene with a patient [Date and time] Vehicle | |||
| Indent69476-0 | Responding unit arrived with the patient at the destination or transfer point [Date and time] Vehicle | |||
| Indent69477-8 | Unit was back in service and available for response [Date and time] Vehicle | |||
| Indent69470-3 | Dispatch was notified by the 911 call taker [Date and time] Facility | |||
| Indent8716-3 | Vital signs | |||
| Indent8480-6 | Systolic blood pressure | mm[Hg] | ||
| Indent8462-4 | Diastolic blood pressure | mm[Hg] | ||
| Indent8867-4 | Heart rate | {beats}/min;{counts/min} | ||
| Indent9279-1 | Respiratory rate | {breaths}/min;{counts/min} | ||
| Indent59408-5 | Oxygen saturation in Arterial blood by Pulse oximetry | % | ||
| Indent67520-7 | Stroke scale score | |||
| Indent56840-2 | Pain score | {score} | ||
| Indent67775-7 | Level of responsiveness (AVPU) | |||
| Indent2339-0 | Blood glucose level | mg/dL | ||
| Indent19911-7 | Carbon monoxide level | cm3/min/mm[Hg] | ||
| Indent19889-5 | Carbon dioxide level | % | ||
| Indent67519-9 | The cardiac rhythm and other electrocardiography findings associated with the patient | |||
| Indent9267-6 | Glasgow coma score eye opening | |||
| Indent9268-4 | Glasgow coma score motor | |||
| Indent9270-0 | Glasgow coma score verbal | |||
| Indent55285-1 | Glasgow coma score qualifier | |||
| Indent9269-2 | Glasgow coma score total | {score} |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.46
- Last Updated
- Version 2.64
- Change Reason
- Based on Clinical LOINC Committee approval on 2/2014, the Component was changed from 'Trauma summary registry report' and Method was changed from '{Provider}' to harmonize with the current LOINC Document Ontology model.
- Order vs. Observation
- Both
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38852-6 | Summary registry report| |
| LG39060-5 | Trauma| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de registro resumido: |
| it-IT | Italian (Italy) | Sintesi della registrazione: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Referto |
| zh-CN | Chinese (China) | 摘要登记报告: 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=74198-3
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright