Version 2.78

Fully-Specified Name

Component
Episode of care medical records
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method
Physician

Additional Names

Short Name
Physician med records

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Change Reason
Updated Component from "Records.total" to "Episode of care medical records", Timing from "Enctr" to "Pt" and Class from ATTACH.CLINRPT to DOC.MISC based on review with the HL7 Attachments Workgroup.
Order vs. Observation
Both
HL7® Attachment Structure
No implementation guide exists

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) registros.total:hallazgo:duración del encuentro:^paciente:Múltiple:médico
es-MX Spanish (Mexico) Episodio de historia clínica asistencial:Tipo:Punto temporal:^ Paciente:Documento:Médico
it-IT Italian (Italy) Episodio di cura, cartelle cliniche:Osservazione:Pt:^Paziente:Doc:Medico
Synonyms: Cartelle cliniche dell''episodio di cura Cartelle mediche Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verslag van zorgepisode:bevinding:moment:^patiënt:document:arts
zh-CN Chinese (China) 照护服务节段病历:发现:时间点:^患者:文档型:医师
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;插曲;片断;场面;情节;发作 内科医师;内科医生;医生 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 照护服务节段照护服务节段（医疗服务历程、照护服务历程、照护历程、医疗护理服务历程、医疗护理历程、医疗历程、历程、病程、情节、事件、片段、照护服务片段、照护片段、照护情节、照护事件、发生期、患病期、发作期、事件发生期、情节发生期、事件持续时间、情节持续时间、次、回）病历（医学记录、病案） 病历;病案;医疗记录;医疗档案

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=11516-2