Version 2.78

Term Description

Hospital discharge physical findings records a narrative description of the patient's physical findings.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Hospital discharge physical findings
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hospital discharge physical findings

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
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
59271-7 Hospital discharge summary panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Krankenhausentlassbefund der körperlichen Untersuchungen:Befund:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) hallazgos físicos al momento del alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Hallazgos físicos al alta hospitalaria:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Examen physique de sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione Osservazioni fisiche in dimissione ospedaliera paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis ontslag lichamelijke bevindingen:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Госпитализация выбытие физикальные находки:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Выписка Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院体格检查发现:发现:时间点:^患者:叙述型:
Synonyms: 体格检查（查体、体检、身体检查、肉体检查）发现（所见）;查体发现;查体所见 允许...离开(医院、军队);(从监狱)释放 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 医院出院体格检查（查体、体检、身体检查、肉体检查）发现（所见）;医院出院查体发现;医院出院查体所见 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 病院 院

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=10184-0