|
Patient ID data DEEDS
|
|
Facility & Practitioner ID data DEEDS
|
|
ED payment data DEEDS
|
|
ED arrival and 1st assessment data DEEDS
|
|
ED H&P Exam Data DEEDS
|
|
Pain Assessment Pnl
|
|
ED procedures & results DEEDS
|
|
ED medication data DEEDS
|
|
ED dispo & Dx data DEEDS
|
|
Pain cat
?
|
|
|
|
Pain exacerbating factors Reported
E
|
|
|
|
Operative note indications Imp
|
|
|
|
ED dc dispo
|
|
|
|
Birth date
|
|
{mm/dd/yyyy}
|
|
Federal provider number:ID:Pt:Facility:Nom:
|
|
|
|
Arrival time documented Clock time
|
|
{clock_time}
|
|
Illness or injury onset date and time
|
|
|
|
Payment sources Doc
?
|
|
|
|
Medication administered
?
|
|
|
|
Pain scale type
|
|
|
|
Surgery procedure
E
|
|
|
|
IP practitioner
|
|
|
|
Name:-:Pt:^Patient:Set:
|
|
|
|
State provider # Facility
|
|
|
|
Transport mode EMS Sys
|
|
|
|
Injury incident description
|
|
|
|
Annotation comment Imp
?
|
|
|
|
Nonverb pain ind
?
|
|
|
|
ED procedure result type
|
|
|
|
Medication.discharge:Find:Pt:^Patient:Nar:
|
|
|
|
Sex
|
|
|
|
Ambulance transport unit EMS Sys
|
|
|
|
Injury cause
|
|
|
|
Care process or plan
|
|
|
|
Pain quality
E
|
|
|
|
ED procedure result observation Imp
|
|
|
|
Payment Dx
|
|
|
|
Race
|
|
|
|
Ambulance transport agency EMS Sys
|
|
|
|
Injury location
|
|
|
|
Bdy site
E
|
|
|
|
EKG impression
|
|
|
|
Medication prescribed
E
|
|
|
|
Ethnicity Computed
?
|
|
|
|
Referral Source Class
|
|
|
|
Injury associated activity
|
|
|
|
Anatomic part Laterality
|
|
|
|
EKG impression
|
|
|
|
Medication dispensed
|
|
|
|
Phone #
?
|
|
|
|
Chief complaint+Reason for visit
?
|
|
|
|
Injury intent
|
|
|
|
Problem frequency
|
|
|
|
Radiology studies:Cmplx:-:^Patient:Set:
|
|
Amount ED discharge meds to be dispensed
|
|
{#}
|
|
Account #
|
|
|
|
Initial visit for chief complaint
|
|
|
|
Safety equipment used
|
|
|
|
Pain severity Reported
|
|
|
|
Relevant Dx tests/lab data
|
|
|
|
ED service level
?
|
|
|
|
Social Security #
|
|
|
|
Acuity assess 1st enctr
|
|
|
|
Hx of Medication use
?
|
|
|
|
Pain severity Wong-Baker FACES Scale
?
E
|
|
|
|
Laboratory studies:Cmplx:-:^Patient:Set:
|
|
Patient problem outcome
|
|
|
|
Usual occupation
?
|
|
|
|
Responsiveness assessment 1st enctr
|
|
|
|
Source of info
?
|
|
|
|
Pain severity Score VAS
|
|
{score}
|
|
Pulmonary studies:Cmplx:-:^Patient:Set:
|
|
ED outcome
|
|
|
|
Hx of Usual industry
|
|
|
|
Individuals accompanying patient to ED
|
|
|
|
Chief complaint Reported
?
|
|
|
|
Nonpharm pain intervention
|
|
|
|
Cardiology monitoring
|
|
ED patient satisfaction report type
|
|
|
|
Emergency contact info Pnl
|
|
Prehospital care
|
|
|
|
Reason for visit
?
|
|
|
|
FLACC Pain Assessment Pnl
?
©
|
|
Imp & review of lab results
|
|
|
|
Time of death
|
|
|
|
Patient ID # or Provider Acct #
|
|
|
|
Time placed into treatment area
|
|
|
|
Presenting problem
|
|
|
|
Pain assessment Imp
|
|
|
|
Cause of death
?
|
|
|
|
Episode unique ID
|
|
|
|
Patient location
|
|
|
|
Hx of Pres illness
?
|
|
|
|
Dx
E
|
|
|
|
GCS eye 1st enctr
|
|
|
|
Problem description
|
|
|
|
Prov assuming resp for care
|
|
GCS verbal 1st enctr
|
|
|
|
Problem prior evaluation
|
|
|
|
GCS motor 1st enctr
|
|
|
|
Problem diagnostic considerations
|
|
|
|
BP sys 1st enctr
|
|
mm[Hg]
|
|
Problem context
|
|
|
|
BP dias 1st enctr
|
|
mm[Hg]
|
|
Problem exacerbating factors
E
|
|
|
|
Heart rate 1st enctr
|
|
{beats}/min
|
|
Pain initiating event Reported
|
|
|
|
Resp rate 1st enctr
|
|
{breaths}/min
|
|
Problem alleviating factors
E
|
|
|
|
Bdy temp 1st enctr
|
|
|
|
Pain alleviating factors Reported
E
|
|
|
|
Pregnancy status Reported
?
E
|
|
|
|
Problem response to therapy
|
|
|
|
Date last C tetani immunization
|
|
|
|
Problem quality or description
|
|
|
|
Pain quality
E
|
|
|
|
Problem location
|
|
|
|
Pain primary location Reported
E
|
|
|
|
Pain radiation
?
|
|
|
|
Problem time course
|
|
|
|
Pain temporal pattern Reported
E
|
|
|
|
Problem frequency
|
|
|
|
Sym dur during occurrences or episodes
|
|
|
|
Pain duration Reported
E
|
|
|
|
Onset of painful contractions
|
|
|
|
Time contractions became regular
|
|
|
|
Time membranes ruptured
|
|
|
|
Time last ate solid food
|
|
|
|
Time last drank liquid
|
|
|
|
Limitations in obtaining history
|
|
|
|
Problem associated signs+symptoms
|
|
|
|
Problem list Reported
|
|
|
|
Hx of Past illness
?
|
|
|
|
General health Reported
?
|
|
|
|
Hx of Major illnesses and injuries
|
|
|
|
Pregnancies Hx
|
|
|
|
Allergies &or adverse reactions Doc
?
|
|
|
|
Hx of Adverse drug rxn
?
|
|
|
|
Medication allergy Reported
|
|
|
|
Hx of Surg proc
|
|
|
|
Chief complaint+Reason for visit
?
|
|
|
|
Hx of Hospitalization
|
|
|
|
Hx of Childhood diseases
|
|
|
|
Hx of Outpt visits
|
|
|
|
Hx medical device use
?
E
|
|
|
|
Hx of Allergies
|
|
|
|
Hx of Growth+Development
|
|
|
|
Immunization status Reported
|
|
|
|
Hx of Immunization
?
|
|
|
|
C tetani immunization status
|
|
|
|
RABV immunization status
|
|
|
|
FLUV immunization status
|
|
|
|
B pert immunization status
|
|
|
|
HAV immunization status
|
|
|
|
MeV status
|
|
|
|
HIB immunization status
|
|
|
|
HPV immunization status
|
|
|
|
RV immunization status
|
|
|
|
N men immunization status
|
|
|
|
S pneum polyvalent immunization status
|
|
|
|
S pneum conjugated immunization status
|
|
|
|
C diphtheriae immunization status
|
|
|
|
PV immunization status
|
|
|
|
VZV status
?
|
|
|
|
HBV status
?
|
|
|
|
HCV status
|
|
|
|
HIV status
|
|
|
|
RUBV status
?
|
|
|
|
CMV status
|
|
|
|
Feeding and dietary status Reported
|
|
|
|
Functional status note
?
|
|
|
|
Hx of Cogn func
|
|
|
|
Social Hx
?
|
|
|
|
Marital status+living arrang
|
|
|
|
Current employment Reported
|
|
|
|
Hx of Occupation
|
|
|
|
Hx of Occupational exposure
|
|
|
|
Military service
|
|
|
|
Hx of Alcohol use
|
|
|
|
Alcoholic drinks/drinking D Reported
|
|
/d
|
|
Alcohol binge episodes/M Reported
|
|
{#}/mo
|
|
Alcoholic drinks per W Reported
?
|
|
{#}/wk
|
|
Hx of Tobacco use
|
|
|
|
Cigs smoked (pack/day) nRate Reported
|
|
{#}/d
|
|
Cigs smoked (pack/year) nRate Reported
|
|
{#}/a
|
|
Hx of Other nonmedical drug use
|
|
|
|
Type of substance abused
|
|
|
|
Highest level of educ
|
|
|
|
Hx of Sexual behavior
|
|
|
|
Hx of Travel
|
|
|
|
Other social factors Hx
|
|
|
|
Family member diseases Hx
?
|
|
|
|
Review of systems
?
|
|
|
|
Constitutional symptoms
|
|
|
|
Hx of Neurologic disorders
|
|
|
|
Hx of Psychiatric disorders
|
|
|
|
Hx of Endocrine disorders
|
|
|
|
Hx of Hematologic disorders
|
|
|
|
Hx of Allergy+Immunologic disorders
|
|
|
|
Hx of Blood transfusion
|
|
|
|
Hx of Neoplastic disease
|
|
|
|
Hx of Infectious disease
|
|
|
|
Hx of Integumentary disorders
|
|
|
|
Hx of Skin disorders
|
|
|
|
Hx of Brsts disorders
|
|
|
|
Hx of Eyes disorders
|
|
|
|
Hx of ENSMT disorders
|
|
|
|
Hx of Ear disorders
|
|
|
|
Hx of Nose disorders
|
|
|
|
Hx of CVS disorders
|
|
|
|
Hx of Oral cavity disorders
|
|
|
|
Hx of Respiratory disorders
|
|
|
|
Hx of GI disorders
|
|
|
|
Hx of GU disorders
|
|
|
|
Hx of Reproductive disorders
|
|
|
|
Hx of Urinary disorders
|
|
|
|
Hx of Reproductive disorders
|
|
|
|
Hx of Gynecologic system disorders
|
|
|
|
Menstrual Hx Reported
|
|
|
|
Menstrual status Reported
E
|
|
|
|
Birth control method Reported
|
|
|
|
LMP Start date
|
|
{date}
|
|
Pregnancy related history
|
|
|
|
Deliv date Clin est
?
|
|
|
|
Pregnancies
?
|
|
{#}
|
|
Parity
?
|
|
{#}
|
|
Hx of Urinary disorders
|
|
|
|
# Fetuses
|
|
{#}
|
|
Fet Movement
|
|
|
|
Viability of current pregnancy
|
|
|
|
Pregnancy status Reported
?
E
|
|
|
|
Date symptoms of pregnancy 1st noted
|
|
|
|
Hx of Musculoskeletal disorders
|
|
|
|
Phys find
|
|
|
|
1M Apgar Score
|
|
{score}
|
|
5M Apgar Score
|
|
{score}
|
|
10M Apgar Score
|
|
{score}
|
|
Phys find General status
?
|
|
|
|
Acuity assess
|
|
|
|
Vital signs
?
|
|
|
|
Pain severity Reported
|
|
|
|
Pain severity Score VAS
|
|
{score}
|
|
Pain severity Wong-Baker FACES Scale
?
E
|
|
|
|
Pain severity total Score FLACC
©
|
|
{score}
|
|
Pain severity verbal numeric scale Score
|
|
{score}
|
|
Pain severity verbal numeric scale Score
|
|
{score}
|
|
Speed of pain onset Reported
E
|
|
|
|
Chronic pain assessment
|
|
|
|
Capillary refill Time
?
|
|
s
|
|
SaO2 % BldA PulseOx
|
|
%
|
|
Inhaled O2 flow rate
?
|
|
L/min
|
|
Fet Heart rate
|
|
{beats}/min
|
|
QRS Complex nRate Hrt ventrs EKG
|
|
|
|
BP sys/dias
?
|
|
|
|
BP mean
|
|
mm[Hg]
|
|
BP dias
|
|
mm[Hg]
|
|
BP sys
|
|
mm[Hg]
|
|
Heart rate Periph a Palpation
|
|
{beats}/min
|
|
Heart rate rhythm Palpation
E
|
|
|
|
Heart rate
|
|
|
|
Resp rate
|
|
|
|
Body temperature
|
|
Cel
|
|
Weight
|
|
|
|
Weight Measured
|
|
|
|
Body height
|
|
|
|
GCS total
|
|
{score}
|
|
GCS eye
|
|
|
|
GCS verbal
|
|
|
|
GCS motor
|
|
|
|
GCS special circumstances
E
|
|
|
|
Physical exam by body areas
|
|
|
|
Phys find Head
|
|
|
|
Phys find Face
E
|
|
|
|
Phys find Lip
E
|
|
|
|
Phys find Scalp
E
|
|
|
|
Phys find Neck
|
|
|
|
Jugular distention head up 30 deg
|
|
[in_i]
|
|
Phys find Chest
|
|
|
|
Phys find Chest wall
|
|
|
|
Phys find Brsts
|
|
|
|
Phys find Axilla
|
|
|
|
Phys find Hrt
|
|
|
|
Phys find Thorax+Lungs
|
|
|
|
Phys find Abd
|
|
|
|
Phys find Groin
|
|
|
|
Phys find Pelvis
|
|
|
|
Phys find Genitalia
|
|
|
|
Phys find Male genitalia
|
|
|
|
Phys find Prostate
E
|
|
|
|
Phys find Female genitalia
|
|
|
|
Phys find Vagina
E
|
|
|
|
Phys find Uterus
E
|
|
|
|
Phys find Cvx
E
|
|
|
|
Phys find Buttocks
|
|
|
|
Phys find Rectum
|
|
|
|
Phys find Back
|
|
|
|
Phys find Spine
E
|
|
|
|
Phys find Paravertebral muscles
E
|
|
|
|
Phys find Hand
|
|
|
|
Phys find Digits
E
|
|
|
|
Phys find Nail Bed
|
|
|
|
Phys find Wrist
|
|
|
|
Phys find Forearm
|
|
|
|
Phys find Elbow
|
|
|
|
Phys find Upper arm
|
|
|
|
Phys find Should
|
|
|
|
Phys find Ft
|
|
|
|
Phys find Toes
E
|
|
|
|
Phys find Ankle
|
|
|
|
Phys find Calf
|
|
|
|
Phys find Knee
|
|
|
|
Phys find Thigh
|
|
|
|
Phys find Hip
|
|
|
|
Phys find Eye
|
|
|
|
IOP Eye
|
|
mm[Hg]
|
|
Phys find Conjunctiva
E
|
|
|
|
Phys find Cornea
E
|
|
|
|
Phys find Extraocular muscles
E
|
|
|
|
Phys find Eye lid
E
|
|
|
|
Phys find Iris
E
|
|
|
|
Phys find Lacrimal apparatus
E
|
|
|
|
Phys find Optic lens
E
|
|
|
|
Phys find Pupil
E
|
|
|
|
Phys find Retina
|
|
|
|
Phys find Sclera
E
|
|
|
|
Visual acuity study
|
|
|
|
Phys find ENMT
|
|
|
|
Phys find Ear
|
|
|
|
Phys find Tympanic Memb
E
|
|
|
|
Phys find Auditory canal
E
|
|
|
|
Phys find Nose
|
|
|
|
Phys find Palate
|
|
|
|
Phys find Mouth
E
|
|
|
|
Phys find Teeth+gum
E
|
|
|
|
Phys find Tongue
E
|
|
|
|
Phys find Throat
|
|
|
|
Phys find Larynx
E
|
|
|
|
Phys find Tonsil
E
|
|
|
|
Phys find Mouth+Throat+Teeth
|
|
|
|
Phys find CVS
|
|
|
|
Phys find Vesl
|
|
|
|
Pulse strength on exam
|
|
|
|
Phys find Respiratory
|
|
|
|
Phys find GI
|
|
|
|
Phys find GU Tract
|
|
|
|
Phys find Musculoskeletal
|
|
|
|
Phys find Muscle tone
E
|
|
|
|
Phys find Skin
|
|
|
|
Phys find Neurologic
|
|
|
|
Mental status
?
|
|
|
|
Phys find Primitive reflexes
|
|
|
|
Phys find Brain stem reflexes
|
|
|
|
Phys find sensation
E
|
|
|
|
Phys find Motor function
E
|
|
|
|
Phys find Strength
|
|
|
|
Phys find Balance+Coordination
|
|
|
|
Phys find Gait
E
|
|
|
|
Phys find Deep tendon reflexes
|
|
|
|
DTR Achilles
E
|
|
|
|
DTR Biceps
E
|
|
|
|
DTR Brachioradialis
E
|
|
|
|
DTR Patellar
E
|
|
|
|
DTR Triceps
E
|
|
|
|
Phys find Nerves.cranial
E
|
|
|
|
Babinski reflex
|
|
|
|
Psychiatric findings
|
|
|
|
Phys find Hem+Lymph+Immun
|
|
|
|
Phys find LN
E
|
|
|
|
Phys find Endocrine
E
|
|
|
|
Phys find Joint
E
|
|
|
|
Phys find Extremities
|
|
|
|
Adv healthcare directives
?
|
|
|
|
Diagnostic imaging study
|
|
|
|
Blood gas studies:Cmplx:-:^Patient:Set:
|
|
|
|
Continuous ST segment monitoring
|
|
|
|
Prov assuming care uponED dispon
?
|
|
|
|
Emergency contact Name
|
|
|
|
Bronchoscopy study
|
|
|
|
Pain severity Face FLACC
©
|
|
|
|
Study observation:Find:Pt:XXX:Nar:Radiology
?
|
|
|
|
Invasive hemodynamic monitoring
|
|
|
|
Emergency contact Address
|
|
|
|
Chemistry studies:Cmplx:-:^Patient:Set:
|
|
|
|
Polysomnography study
?
|
|
|
|
Pain severity Legs FLACC
©
|
|
|
|
XR Skull Views
|
|
|
|
Hematology studies:Cmplx:-:^Patient:Set:
|
|
|
|
Spirometry study
|
|
|
|
Pain severity Activity FLACC
©
|
|
|
|
Emergency contact Phone #
|
|
|
|
Mixed venous O2 sat monitoring
?
|
|
|
|
Pain severity Cry FLACC
©
|
|
|
|
Coagulation studies:Cmplx:-:^Patient:Set:
|
|
|
|
Emergency contact Relationship to pt
?
|
|
|
|
Cardiac rhythm monitoring
|
|
|
|
XR Spine Views
|
|
|
|
Pain severity Consolability FLACC
©
|
|
|
|
Toxicology studies:Cmplx:-:^Patient:Set:
|
|
|
|
XR C-spine Views
|
|
|
|
XR T-spine Views
|
|
|
|
Microbiology studies:Cmplx:-:^Patient:Set:
|
|
|
|
Pain severity total Score FLACC
©
|
|
{score}
|
|
XR L-spine Views
|
|
|
|
Serology and blood bank studies
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Urinalysis studies:Cmplx:-:^Patient:Set:
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XR Hip Views
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XR Pelvis Views
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Calc and deriv values
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XR Femur Views
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Cardiac biomarkers
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XR Knee Views
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XR Tib+Fib Views
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XR Ankle Views
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XR Foot Views
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XR Should Views
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XR Humerus Views
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XR Radius+Ulna Views
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XR Elbow Views
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XR Wrist Views
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XR Hand Views
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CT Unsp region
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CT Head
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CT C-spine
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CT T-spine
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CT L-spine
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CT Chest
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CT Abd
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CT Pelvis W contr IV
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CT Extr
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MR Unsp region
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MR C+T+L-spine
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MR Brain
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MR C-spine
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MR T-spine
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MR L-spine
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MR Chest
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MR Abd
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MR Pelvis and Hip
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MR Foot
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MR Forearm
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MR Joint
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MR Hand
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MG Brst Dx
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MG Brst screening
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NM Pulm system VP W 133Xe IH+Tc99mMAA IV
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NM Thyroid Views W RNC IV
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PT W RNC IV
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CT Guided PC fluid asp
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CT Guided Bx
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RF Guided Bx
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US Guided Bx
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US Unsp region
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US Head
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US Neck
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US Abd
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US Liver
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US Brst
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US Pelvis
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