82315-3
Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
Active
67840-9 EMS advance directives Narrative NEMSIS
Fully-Specified Name
- Component
- EMS advance directives
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Εκ των προτέρων οδηγίες υπηρεσίας έκτακτης ανάγκης: Synonyms: Εκ των προτέρων οδηγίες Εκ των προτέρων οδηγίες υπηρεσίας έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Directivas anticipadas de EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, direttive anticipate: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d Testamenti biologici; |
zh-CN | Chinese (China) | 急救医疗服务事前指示: Synonyms: EMS National Emergency Medical Services Information System; |
48765-2 Allergies and adverse reactions Document
Term Description
Contains a list and description of any allergies or adverse reactions pertinent to current or past medical history. At a minimum this section should contain currently active and any relevant historical allergies and adverse reactions.
Fully-Specified Name
- Component
- Allergies &or adverse reactions
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.21
- Last Updated
- Version 2.73 (MIN)
- Change Reason
- Previous Releases: Edited Component part from "Allergies, adverse reactions, alerts" to "Allergies &or adverse reactions." We removed the word "alerts" because it was potentially confusing by implying that it may contain other kinds of warnings (as a arbitrary example: public health disease outbreak notifications) when in fact it was always intended to be the typical "allergies" section.;
- Order vs. Observation
- Both
Member of these Panels
LOINC | Long Common Name |
---|---|
57082-0 | Antepartum record panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 sections |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
82315-3 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Allergien und unerwünschte Wirkungen: |
el-GR | Greek (Greece) | Αλλεργίες και/ή ανεπιθύμητες ενέργειες: Synonyms: Αλλεργίες Αλλεργίες και/ή ανεπιθύμητες ενέργειες Εύρεση |
es-MX | Spanish (Mexico) | Alergias y reacciones adversas: |
it-IT | Italian (Italy) | Allergie &o reazioni avverse: Synonyms: Allergie e reazioni avverse Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | allergieën en/of allergische reacties: |
ru-RU | Russian (Russian Federation) | Аллергии &или неблагоприятные реакции: Synonyms: Документ Точка во времени; |
zh-CN | Chinese (China) | 变态反应和或不良反应: Synonyms: 临床文档型; |
67659-3 EMS billing Narrative NEMSIS
Term Description
Billing-specific condition & service level
Fully-Specified Name
- Component
- EMS billing
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Τιμολόγηση υπηρεσιών έκτακτης ανάγκης: Synonyms: Τιμολόγηση υπηρεσιών έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Facturación EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, fatturazione: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务记账: Synonyms: EMS National Emergency Medical Services Information System; |
67799-7 EMS cardiac arrest event Narrative NEMSIS
Fully-Specified Name
- Component
- EMS cardiac arrest event
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Συμβάν καρδιακής ανακοπής υπηρεσίας έκτακτης ανάγκης: Synonyms: Καρδιακή ανακοπή Συμβάν Συμβάν καρδιακής ανακοπής υπηρεσίας έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Evento de paro cardíaco EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, evento di arresto cardiaco: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务心脏停搏事件: Synonyms: EMS National Emergency Medical Services Information System; |
67844-1 EMS current medications Narrative NEMSIS
Reference Information
Type | Source | Reference |
---|---|---|
Webcontent | NEMSIS | http://www.cdc.gov/nchs/icd.htm RxNorm/ICD9/ICD10 |
Fully-Specified Name
- Component
- EMS current medications
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Τρέχουσα φαρμακευτική αγωγή υπηρεσίας έκτακτης ανάγκης: Synonyms: Τρέχουσα φαρμακευτική αγωγή υπηρεσίας έκτακτης ανάγκης Φαρμακευτική αγωγή |
es-MX | Spanish (Mexico) | Medicamentos actuales de EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, farmaci attuali: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务当前药物: Synonyms: EMS National Emergency Medical Services Information System; |
67660-1 EMS dispatch Narrative NEMSIS
Term Description
Information related to dispatch instructions
Fully-Specified Name
- Component
- EMS dispatch
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Αποστολή υπηρεσιών έκτακτης ανάγκης: Synonyms: Αποστολή υπηρεσιών έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Envío EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, assegnazione: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务调度: Synonyms: EMS National Emergency Medical Services Information System; |
67661-9 EMS disposition Narrative NEMSIS
Term Description
Information related to transportation, destination
Fully-Specified Name
- Component
- EMS disposition
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Διάθεση υπηρεσιών έκτακτης ανάγκης: Synonyms: Διάθεση Διάθεση υπηρεσιών έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Disposición EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, disposizione: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务处置: Synonyms: EMS National Emergency Medical Services Information System; |
67800-3 EMS injury incident description Narrative NEMSIS
Term Description
Appropriate ICD-10 External Cause Code (Minimal Values Provided as an Example), Pedestrian injured in transport accident (ICD-10: V01-V09), Pedal cyclist injured in transport accident (ICD-10: V10-V19), Motorcycle rider injured in transport accident (ICD-10: V20-V29), Occupant of three-wheeled motor vehicle injured in transport accident (ICD-10: V30-V39), Car occupant injured in transport accident (ICD-10: V40-V49), Occupant of pick-up truck or van injured in transport accident (ICD-10: V50-V59), Occupant of heavy transport vehicle injured in transport accident (ICD-10: V60-V69), Bus occupant injured in transport accident (ICD-10: V70-V79), Other land transport accidents (ICD-10: V80-V89), Water transport accidents (ICD-10: V90-V94), Air and space transport accidents (ICD-10: V95-V97), Other and unspecified transport accidents (ICD-10: V98-V99), Falls (ICD-10: W00-W19), Exposure to inanimate mechanical forces (ICD-10: W20-W49), Exposure to animate mechanical forces (ICD-10: W50-W64), Accidental drowning and submersion (ICD-10: W65-W74), Other accidental threats to breathing (ICD-10: W75-W84), Exposure to electric current, radiation and extreme ambient air temperature and pressure (ICD-10: W85-W99), Exposure to smoke, fire and flames (ICD_10: X00-X09), Contact with heat and hot substances (ICD-10: X10-X19), Contact with venomous animals and plants (ICD-10: X20-X29), Exposure to forces of nature (ICD-10: X30-X39), Accidental poisoning by and exposure to noxious substances (ICD-10: X40-X49), Overexertion, travel and privation (ICD-10: X50-X57), Accidental exposure to other and unspecified factors (ICD-10: X58-X59), Intentional self-harm (ICD-10: X60-X84), Assault (ICD-10: X85-Y09), Event of undetermined intent (ICD-10: Y10-Y34), Legal intervention and operations of war (ICD-10: Y35-Y36), Complications of medical and surgical care (ICD-10:Y40-Y84), Sequelae of external causes of morbidity and mortality (ICD-10: Y85-Y89)
Fully-Specified Name
- Component
- EMS injury incident description
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Περιγραφή περιστατικού τραυματισμού υπηρεσίας έκτακτης ανάγκης: Synonyms: Περιγραφή περιστατικού τραυματισμού Περιγραφή περιστατικού τραυματισμού υπηρεσίας έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Descripción del incidente de lesión de EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, descrizione lesioni incidente: Synonyms: Descrizione incidente lesivo National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务损伤事故描述: Synonyms: EMS National Emergency Medical Services Information System; |
67849-0 EMS medications administered Narrative NEMSIS
Fully-Specified Name
- Component
- EMS medications administered
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Χορηγηθείσα φαρμακευτική αγωγή υπηρεσίας έκτακτης ανάγκης: Synonyms: Φαρμακευτική αγωγή Χορηγηθείσα φαρμακευτική αγωγή υπηρεσίας έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Medicamentos EMS administrados: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, farmaci somministrati: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务已施用的药物: Synonyms: EMS National Emergency Medical Services Information System; |
67842-5 EMS past medical history Narrative NEMSIS
Fully-Specified Name
- Component
- EMS past medical history
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Προηγούμενο ιατρικό ιστορικό υπηρεσίας έκτακτης ανάγκης: Synonyms: Ιατρικό ιστορικό Προηγούμενο ιατρικό ιστορικό Προηγούμενο ιατρικό ιστορικό υπηρεσίας έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Antecedentes médicos de EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, storia clinica: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d Storia clinica precedente |
zh-CN | Chinese (China) | 急救医疗服务既往病史: Synonyms: EMS National Emergency Medical Services Information System; |
67781-5 The narrative of the patient care report (PCR)
Fully-Specified Name
- Component
- Summarization of encounter note
- Property
- Hx
- Time
- Pt
- System
- {Setting}
- Scale
- Nar
- Method
- {Role}
Long Common Name
Summarization of encounter note Narrative
Basic Attributes
- Class
- NEMSIS
- Type
- Clinical
- First Released
- Version 2.40
- Last Updated
- Version 2.54 (MAJ)
- Change Reason
- Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
Member of these Panels
LOINC | Long Common Name |
---|---|
82315-3 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
84428-2 | National EMS Information System - version 3 set |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Περίληψη σημειώματος συνάντησης: Synonyms: Ιστορικό Περίληψη σημειώματος συνάντησης Σημείωση |
es-MX | Spanish (Mexico) | Resumen de la nota del encuentro: |
it-IT | Italian (Italy) | Riepilogo dell'incontro, note: Synonyms: National EMS Information System data - dati del Si Punto nel tempo (episodio) Ruolo non specificato Storia; |
nl-NL | Dutch (Netherlands) | samenvatting van contact: Synonyms: anamnese |
zh-CN | Chinese (China) | 就医记录摘要: Synonyms: National Emergency Medical Services Information System; |
67658-5 EMS exposures or injuries of EMS personnel Provider Narrative NEMSIS
Term Description
e.g. EMT exposure, needle stick, etc
Fully-Specified Name
- Component
- EMS exposures or injuries of EMS personnel
- Property
- -
- Time
- Pt
- System
- Provider
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Έκθεση των υπηρεσιών έκτακτης ανάγκης ή τραυματισμοί του προσωπικού έκτακτης ανάγκης: Synonyms: Έκθεση των υπηρεσιών έκτακτης ανάγκης ή τραυματισμοί του προσωπικού έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Exposiciones de EMS o lesiones del personal de EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, esposizioni o lesioni del personale pronto intervento sanitario: Synonyms: National EMS Information System data - dati del Si Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务人员的急救医疗服务暴露或损伤: Synonyms: EMS National Emergency Medical Services Information System; |
29545-1 Physical findings Narrative
Fully-Specified Name
- Component
- Physical findings
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- Observed
Basic Attributes
- Class
- H&P.PX
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.63 (MIN)
Member of these Panels
LOINC | Long Common Name |
---|---|
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
82315-3 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Φυσικά ευρήματα: Synonyms: Εύρεση |
es-AR | Spanish (Argentina) | hallazgos físicos: |
es-MX | Spanish (Mexico) | Hallazgos físicos: |
fr-BE | French (Belgium) | Examen physique: |
it-IT | Italian (Italy) | Osservazioni fisiche: Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | lichamelijke bevindingen: |
pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Физикальные находки: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 体格检查发现: Synonyms: 体格检查(查体、 |
29554-3 Procedure Narrative
Term Description
Procedure records the descriptions of the procedure with an extensive narrative and may include procedure site preparation, pertinent details related to measurements and markings, procedure times, instrumentation, and vital signs and other monitoring data.
Fully-Specified Name
- Component
- Procedure
- Property
- Type
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Basic Attributes
- Class
- H&P.PX
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.40 (MIN)
Member of these Panels
LOINC | Long Common Name |
---|---|
84907-5 | Cancer pathology panel - Colorectal cancer specimen |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
81241-2 | Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections |
82315-3 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72227-2 | Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Prozedur oder Maßnahme: |
el-GR | Greek (Greece) | Διαδικασία: Synonyms: Type |
es-AR | Spanish (Argentina) | procedimiento: |
es-ES | Spanish (Spain) | Procedimiento: |
es-MX | Spanish (Mexico) | Procedimiento: |
it-IT | Italian (Italy) | Procedura: Synonyms: Esame obbiettivo paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | verrichting: |
pt-BR | Portuguese (Brazil) | Procedimento: Synonyms: Typ; |
ru-RU | Russian (Russian Federation) | Вмешательство: Synonyms: Описательный Процедура Точка во времени; |
zh-CN | Chinese (China) | 操作项目: Synonyms: 体格检查小节与指标; |
67663-5 EMS protocol Narrative NEMSIS
Term Description
Protocol followed by crew
Fully-Specified Name
- Component
- EMS protocol
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Πρωτόκολλο υπηρεσιών έκτακτης ανάγκης: Synonyms: Πρωτόκολλο υπηρεσιών έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Protocolo EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, protocollo: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务方案: Synonyms: EMS National Emergency Medical Services Information System; |
67664-3 EMS response Narrative NEMSIS
Term Description
Places, odometer readings
Fully-Specified Name
- Component
- EMS response
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Απόκριση υπηρεσιών έκτακτης ανάγκης: Synonyms: Απόκριση υπηρεσιών έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Respuesta de EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, risposta: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务响应: Synonyms: EMS National Emergency Medical Services Information System; |
67665-0 EMS scene Narrative NEMSIS
Term Description
Location, other services present, number of patients
Fully-Specified Name
- Component
- EMS scene
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Σημείο υπηρεσιών έκτακτης ανάγκης: Synonyms: Σημείο υπηρεσιών έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Escena EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, luogo: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务现场: Synonyms: EMS National Emergency Medical Services Information System; |
67666-8 EMS situation Narrative NEMSIS
Term Description
Complaint
Fully-Specified Name
- Component
- EMS situation
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Κατάσταση υπηρεσιών έκτακτης ανάγκης: Synonyms: Κατάσταση υπηρεσιών έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Situación EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, situazione: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务患者情况: Synonyms: EMS National Emergency Medical Services Information System; |
67843-3 EMS social history Narrative NEMSIS
Fully-Specified Name
- Component
- EMS social history
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Κοινωνικό ιστορικό υπηρεσίας έκτακτης ανάγκης: Synonyms: Κοινωνικό ιστορικό Κοινωνικό ιστορικό υπηρεσίας έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Historia social de EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, stile di vita: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Servizi medici di emergenza, storia so Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务社会史: Synonyms: EMS National Emergency Medical Services Information System; |
67667-6 EMS times Narrative NEMSIS
Term Description
Times recorded to assess delays
Fully-Specified Name
- Component
- EMS times
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- NEMSIS
Basic Attributes
- Class
- PANEL.NEMSIS
- Type
- Clinical
- First Released
- Version 2.38
- Last Updated
- Version 2.50 (MIN)
- Panel Type
- Panel
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
el-GR | Greek (Greece) | Χρόνοι υπηρεσιών έκτακτης ανάγκης: Synonyms: Χρόνοι υπηρεσιών έκτακτης ανάγκης |
es-MX | Spanish (Mexico) | Tiempos de EMS: |
it-IT | Italian (Italy) | Servizi Medici di Emergenza, tempi: Synonyms: National EMS Information System data - dati del Si paziente Punto nel tempo (episodio) Set di dati del Sistema Informativo del Servizio d |
zh-CN | Chinese (China) | 急救医疗服务时间: Synonyms: EMS National Emergency Medical Services Information System; |
8716-3 Vital signs
Term Description
The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included.
Fully-Specified Name
- Component
- Vital signs
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- Observed
Basic Attributes
- Class
- H&P.PX
- Type
- Clinical
- First Released
- Version 1.0h(3)
- Last Updated
- Version 2.73 (MIN)
- Common Test Rank Get Info
- 576
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 sections |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
82315-3 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Vitalparameter: |
el-GR | Greek (Greece) | Ζωτικά σημεία: Synonyms: Εύρεση Ζωτικά σημεία |
es-MX | Spanish (Mexico) | Signos vitales: |
es-AR | Spanish (Argentina) | hallazgos físicos: |
fr-BE | French (Belgium) | Signes vitaux: |
it-IT | Italian (Italy) | Segni vitali: Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | vitale functies: |
pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Жизненно важные функции: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 生命体征: Synonyms: 体格检查小节与指标; |