Version 2.78

Part Description

LP72701-3   History and physical note
History and physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. Source: HL7

Fully-Specified Name

Component
History and physical note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Cardiac surgery

Additional Names

Short Name
Cardiac surgery H&P note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.74
Last Updated
Version 2.74
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG39111-6 Cardiac surgery|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38753-6 History and physical note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Anamnesi e visita medica:Osservazione:Pt:{Setting}:Doc:Chirurgia cardiaca
Synonyms: Documentazione dell''ontologia Operazione chirurgica Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verslag voorgeschiedenis en lichamelijk onderzoek:bevinding:moment:{instelling}:document:cardiochirurgie
zh-CN Chinese (China) 病史与体格检查记录:发现:时间点:{环境}:文档型:心脏外科学
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 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 外科;外科手术;手术;手术室 心脏外科;心脏外;心外;心脏外科学手术;心脏外科手术;心脏手术;心脏外科学（心脏外科学手术、心脏外科、心脏外、心外、心脏外科手术、心脏手术） 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 笔记;按语;注释;说明;票据;单据;证明书

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=101028-9