Version 2.77

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
IndentIndent76066-0 AIS version R
IndentIndent75890-4 AIS predot code O
IndentIndent75891-2 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}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38852-6 Summary registry report|ANYRole|ANYSetting
LG39060-5 Trauma|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Informe de registro resumido:Tipo:Punto temporal:{Configuración}:Documento:Trauma
it-IT Italian (Italy) Sintesi della registrazione:Osservazione:Pt:{Setting}:Doc:Trauma
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Referto
zh-CN Chinese (China) 摘要登记报告:发现:时间点:{环境}:文档型:创伤专业
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 创伤;损伤;外伤;创伤(损伤、外伤)专业 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 报道;汇报;调查报告;报表;报导 摘要注册报告;摘要注册库报告;摘要注册处报告;摘要登记处报告;摘要注册中心报告 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 注册报告;注册处报告;登记处报告;注册中心报告;登记库报告;注册库报告

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