26443-2
Clinical reports.non lab claims attachment
Active
28650-0 Clinical notes and chart sections Set
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Clinical notes and chart sections
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.67
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | anotaciones médicas y secciones de la historia clínica: |
| it-IT | Italian (Italy) | Note cliniche e sezioni di cartella: Synonyms: Allegato Allegato referto clinico Complesso paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Клинические записи и карта разделы: Synonyms: Клинические записи и разделы карты Комплекс |
| zh-CN | Chinese (China) | 临床记录与病历小节: Synonyms: 临床信息附件集; |
28562-7 Chart section Set
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Chart section
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.40
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | sección de la cartilla: |
| it-IT | Italian (Italy) | Sezione di cartella: Synonyms: Allegato Allegato referto clinico Complesso paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Карта раздел: Synonyms: Комплекс Раздел карты |
| zh-CN | Chinese (China) | 医疗记录小节: Synonyms: 临床信息附件集; |
11485-0 Anesthesia records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Anesthesia records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Anesthesia records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
- HL7® Attachment Structure
- No IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Registros de anestesia: |
| es-AR | Spanish (Argentina) | registros de anestesia: |
| it-IT | Italian (Italy) | Anestesia, registri: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | anesthesiedossier: |
| ru-RU | Russian (Russian Federation) | Анестезия записи: Synonyms: Документ Записи об анестезии |
| zh-CN | Chinese (China) | 麻醉记录: Synonyms: 临床文档型; |
11486-8 Chemotherapy records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Chemotherapy records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Chemotherapy records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Registros de quimioterapia: |
| es-AR | Spanish (Argentina) | registros de quimioterapia: |
| it-IT | Italian (Italy) | Chemioterapia, registri: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | chemotherapiedossier: |
| ru-RU | Russian (Russian Federation) | Химиотерапия записи: Synonyms: Документ Записи по химиотерапии |
| zh-CN | Chinese (China) | 化学疗法记录: Synonyms: 临床文档型; |
29751-5 Critical care records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Critical care records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Critical care records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | registro de atención crítica: |
| es-MX | Spanish (Mexico) | Registros de cuidados críticos: |
| it-IT | Italian (Italy) | Registri di assistenza critica: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | IC-dossier: |
| ru-RU | Russian (Russian Federation) | Критическое состояние помощь записи: Synonyms: Документ Записи о помощи - интенсивной терапии и реанимации |
| zh-CN | Chinese (China) | 危重病监护记录: Synonyms: 临床文档型; |
29749-9 Dialysis records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Dialysis records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Dialysis records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Dialysebericht: |
| es-AR | Spanish (Argentina) | registros de diálisis: |
| es-MX | Spanish (Mexico) | Registros de diálisis: |
| fr-FR | French (France) | Dossier de dialyse: |
| it-IT | Italian (Italy) | Registri dialisi: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | dialysedossier: |
| ru-RU | Russian (Russian Federation) | Диализ записи: Synonyms: Документ |
| zh-CN | Chinese (China) | 透析记录: Synonyms: 临床文档型; |
15508-5 Labor and delivery records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Labor and delivery records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Labor and delivery records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0k
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
- HL7® Attachment Structure
- No IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Registros de trabajo de parto y parto: |
| es-AR | Spanish (Argentina) | registros de parto y trabajo de parto: |
| it-IT | Italian (Italy) | Travaglio e parto, registri: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | dossier zwangerschap en bevalling: |
| ru-RU | Russian (Russian Federation) | Роды и родоразрешение записи: Synonyms: Документ Записи о роды и родоразрешение |
| zh-CN | Chinese (China) | 临产和分娩记录: Synonyms: 临产（阵痛）和分娩记录（病历、 |
11503-0 Medical records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Medical records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Medical records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
- HL7® Attachment Structure
- No IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Registros médicos: |
| es-AR | Spanish (Argentina) | registros médicos: |
| it-IT | Italian (Italy) | Cartelle cliniche: Synonyms: Cartelle mediche Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | medisch dossier: |
| ru-RU | Russian (Russian Federation) | Медицинские записи: Synonyms: Документ |
| zh-CN | Chinese (China) | 病历类: Synonyms: 临床文档型; |
29750-7 Neonatal intensive care records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Neonatal intensive care records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Neonatal intensive care records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | registros de atención neonatal intensiva: |
| es-MX | Spanish (Mexico) | Registros de cuidados intensivos neonatales: |
| it-IT | Italian (Italy) | Registri di terapia intensiva neonatale: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | neonatale intensieve zorg dossier: |
| ru-RU | Russian (Russian Federation) | Неонатальная интенсивная помощь записи: Synonyms: Документ |
| zh-CN | Chinese (China) | 新生儿重症监护记录: Synonyms: 临床文档型; |
11543-6 Nursery records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Nursery records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Nursery records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Registros de guardería: |
| es-AR | Spanish (Argentina) | registros de sala de recién nacidos: |
| it-IT | Italian (Italy) | Registri nido ospedaliero: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | verpleegkundig dossier: |
| ru-RU | Russian (Russian Federation) | Детская комната записи: Synonyms: Документ |
| zh-CN | Chinese (China) | 婴儿室记录: Synonyms: 临床文档型; |
29752-3 Perioperative records
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Perioperative records
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Perioperative records
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | registros perioperatorios: |
| es-MX | Spanish (Mexico) | Registros perioperatorios: |
| it-IT | Italian (Italy) | Documenti perioperatori: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | peri-operatief dossier: |
| ru-RU | Russian (Russian Federation) | Периоперационные записи: Synonyms: Документ |
| zh-CN | Chinese (China) | 围手术期记录: Synonyms: 临床文档型; |
46209-3 Provider orders
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Provider orders
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Provider orders
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.17
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 82811-1 | Nurse summary note - recommended sections |
| 74449-0 | Patient plan of care - recommended IHE set |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Anforderung: Synonyms: Auftrag |
| es-MX | Spanish (Mexico) | Órdenes de proveedores: |
| it-IT | Italian (Italy) | Provider, ordini: Synonyms: Documentazione miscellanea Miscellanea Ordini del care provider Osservazione paziente |
| pt-BR | Portuguese (Brazil) | Encomendas ao fornecedor: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Провайдер заказы: Synonyms: Документ |
| zh-CN | Chinese (China) | 服务提供者医嘱: Synonyms: 临床文档型; |
11534-5 Temperature charts
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Temperature charts
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Temp charts
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Gráficos de temperatura: |
| es-AR | Spanish (Argentina) | fichas de temperatura: |
| it-IT | Italian (Italy) | Grafici della temperatura: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | temperatuuroverzicht: |
| pt-BR | Portuguese (Brazil) | Gráficos de temperatura: Synonyms: ; |
| ru-RU | Russian (Russian Federation) | Температурные карты: Synonyms: Документ Температурные листы |
| zh-CN | Chinese (China) | 体温单: Synonyms: Temperature charts; |
28563-5 Care provider notes Set
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Care provider notes
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.67
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | CARE PROVIDER NOTES: |
| it-IT | Italian (Italy) | Note del care provider: Synonyms: Allegato Allegato referto clinico Complesso paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Помощь провайдер записи: Synonyms: Записи провайдера помощи Комплекс |
| zh-CN | Chinese (China) | 医疗护理服务提供者记录: Synonyms: 临床信息附件集; |
28654-2 Attending Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Attending
Additional Names
- Short Name
- Attend Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.65
- Change Reason
- Changed Method from 'Attending physician' to 'Physician attending'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values.; Updated "Physician attending" in Method to "Attending" based on Clinical LOINC Committee review and approval (10/2018).
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39003-5 | Attending| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
18733-6 Attending Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Attending
Additional Names
- Short Name
- Attend Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.73
- Change Reason
- Changed Method from 'Attending physician' to 'Physician attending'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values. Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Updated "Physician attending" in Method to "Attending" based on Clinical LOINC Committee review and approval (10/2018).
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39003-5 | Attending| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de progreso: |
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28581-7 Chiropractic medicine Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Chiropractic medicine
Additional Names
- Short Name
- Chiropractic med Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39074-6 | Chiropractic medicine| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: chiropraxie evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28580-9 Chiropractic medicine Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Chiropractic medicine
Additional Names
- Short Name
- Chiropractic med Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39074-6 | Chiropractic medicine| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evolución: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: Synonyms: chiropraxie |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28572-6 Dentistry Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28583-3 Dentist Operation note
Part Descriptions
LP73465-4 Surgical operation note
Surgical operation note (Operative note) is note or report created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnoses, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report provides details to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Operative note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de intervención quirúrgica: |
| es-MX | Spanish (Mexico) | Nota de operación quirúrgica: |
| fr-BE | French (Belgium) | Note opération chirurgicale.: |
| it-IT | Italian (Italy) | Nota di operazione chirurgica: Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | operatieverslag: |
| zh-CN | Chinese (China) | 外科手术记录: Synonyms: 临床文档型; |
28577-5 Dentistry procedure note
Part Descriptions
LP74249-1 Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Procedure note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38811-2 | Procedure note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de procedimiento: |
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| fr-BE | French (Belgium) | Note de procédure: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: verslag procedure |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
28617-9 Dentistry Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| pt-BR | Portuguese (Brazil) | Anotação de avaliação subsequente: Synonyms: ; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28618-7 Dentistry Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.52
- Change Reason
- Component was changed from 'Visit note' to 'Note'. Edit based on Clinical LOINC Committee approval at 8/16/2011 meeting to harmonize existing terms with Document Ontology values.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38748-6 | Note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: |
| pt-BR | Portuguese (Brazil) | Anotação de visita: Synonyms: Finding; |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
34745-0 Nurse Discharge summary
Part Descriptions
LP72467-1 Discharge summary note
Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition and disposition at discharge, information provided to the patient and family, and provisions for follow-up care.
Source: HL7
Fully-Specified Name
- Component
- Discharge summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse D/C sum
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.11
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38746-0 | Discharge summary note| |
| LG38952-4 | Nurse| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Entlassungsbrief Ärztlich: Synonyms: Bericht Entlassungsbrief aus stationärer Behandlung (Arzt); |
| es-AR | Spanish (Argentina) | nota de resumen en el momento del alta: |
| es-MX | Spanish (Mexico) | Nota de resumen de alta: |
| fr-BE | French (Belgium) | Note résumée de sortie: |
| it-IT | Italian (Italy) | Lettera di dimissione ospedaliera: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | samenvattende ontslagbrief: |
| zh-CN | Chinese (China) | 出院摘要记录: Synonyms: 临床文档型; |
29753-1 Nurse Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38952-4 | Nurse| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28623-7 Nurse Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38952-4 | Nurse| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| pt-BR | Portuguese (Brazil) | Anotação de avaliação subsequente: Synonyms: ; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28651-8 Nurse Transfer note
Part Descriptions
LP73546-1 Transfer summary note
Transfer summary notes are generated by the originating institution. The setting (when specified) is the facility the patient is being transferred out of (not where they are going).
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Transfer summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse Transfer sum note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Change Reason
- Updated Component from "Transfer summarization note" to harmonize terms within the existing Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38952-4 | Nurse| |
| LG38744-5 | Transfer summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Transferbericht: Synonyms: Bericht Transferbericht |
| es-AR | Spanish (Argentina) | TRANSFER SUMMARIZATION NOTE: |
| es-MX | Spanish (Mexico) | Transferir nota de resumen: |
| fr-BE | French (Belgium) | Note résumée de transfert: |
| it-IT | Italian (Italy) | Traferimento, nota di sintesi: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | samenvatting van overdracht: |
| zh-CN | Chinese (China) | 移交摘要记录: Synonyms: 临床文档型; |
28621-1 Nurse practitioner Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse practitioner
Additional Names
- Short Name
- Nurse pract Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG39002-7 | Nurse practitioner| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Anotação de avaliação inicial: Synonyms: ; |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28575-9 Nurse practitioner Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse practitioner
Additional Names
- Short Name
- Nurse pract Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39002-7 | Nurse practitioner| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evolución: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18734-4 Occupational therapy Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Occupational therapy
Additional Names
- Short Name
- OT Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38947-4 | Occupational therapy| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11507-1 Occupational therapy Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Occupational therapy
Additional Names
- Short Name
- OT Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. lso changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38947-4 | Occupational therapy| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28578-3 Occupational therapy Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Occupational therapy
Additional Names
- Short Name
- OT Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.52
- Change Reason
- Component was changed from 'Visit note' to 'Note', systerm was changed from ^Patient to {setting} and class was changed from ATTACH.CLINRPT to DOC.CLINRPT based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that 'Occupational therapy visit note', for example, is essentially the same as a 'Occupational therapy note'. Other parts of term were changed to correspond with current document ontology.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38947-4 | Occupational therapy| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Befund: Synonyms: Bericht |
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
18735-1 Physical therapy Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physical therapy
Additional Names
- Short Name
- PT Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38948-2 | Physical therapy| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11508-9 Physical therapy Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physical therapy
Additional Names
- Short Name
- PT Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. lso changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38948-2 | Physical therapy| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de progreso: |
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28579-1 Physical therapy Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physical therapy
Additional Names
- Short Name
- PT Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.52
- Change Reason
- Component was changed from 'Visit note' to 'Note' and class was changed from ATTACH.CLINRPT to DOC.CLINRPT. Edits based on Clinical LOINC Committee approval at 8/16/2011 meeting to harmonize existing terms with Document Ontology values.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38948-2 | Physical therapy| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Befund: Synonyms: Bericht |
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
28568-4 Physician Emergency department Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- Emergency department
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD ED Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Component was changed from 'Visit note' to 'Note' based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that Occupational therapy visit note, for example, is essentially the same as a Occupational therapy note.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 7894
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41825-7 | Emergency department| |
| LG38748-6 | Note| |
| LG38946-6 | Physician| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: Synonyms: SEH |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
11490-0 Physician Discharge summary
Part Descriptions
LP72467-1 Discharge summary note
Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition and disposition at discharge, information provided to the patient and family, and provisions for follow-up care.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Discharge summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD D/C sum
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Changed Component from 'Discharge summarization note' per the Clinical LOINC Committee decision to harmonize existing terms in the LOINC Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38746-0 | Discharge summary note| |
| LG38946-6 | Physician| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Entlassungsbrief Ärztlich: Synonyms: Bericht Entlassungsbrief aus stationärer Behandlung (Arzt); |
| es-MX | Spanish (Mexico) | Nota de resumen de alta: |
| es-AR | Spanish (Argentina) | nota de resumen en el momento del alta: |
| it-IT | Italian (Italy) | Lettera di dimissione ospedaliera: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | samenvattende ontslagbrief: |
| zh-CN | Chinese (China) | 出院摘要记录: Synonyms: 临床文档型; |
18736-9 Physician Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38946-6 | Physician| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28626-0 Physician History and physical note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- History and physical note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD H&P note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Change Reason
- Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38753-6 | History and physical note| |
| LG38946-6 | Physician| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | HISTORY & PHYSICAL NOTE: |
| es-MX | Spanish (Mexico) | Historia y nota física: |
| it-IT | Italian (Italy) | Anamnesi e visita medica: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag voorgeschiedenis en lichamelijk onderzoek: |
| pt-BR | Portuguese (Brazil) | Histórico e anotações físicas: Synonyms: ; |
| zh-CN | Chinese (China) | 病史与体格检查记录: Synonyms: 临床文档型; |
28573-4 Physician, Operation note
Part Descriptions
LP73465-4 Surgical operation note
Surgical operation note (Operative note) is note or report created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnoses, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report provides details to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD Operative note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38946-6 | Physician| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Operationsbericht: Synonyms: Bericht OP-Bericht |
| es-AR | Spanish (Argentina) | nota de intervención quirúrgica: |
| es-MX | Spanish (Mexico) | Nota de operación quirúrgica: |
| it-IT | Italian (Italy) | Nota di operazione chirurgica: Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | operatieverslag: |
| zh-CN | Chinese (China) | 外科手术记录: Synonyms: 临床文档型; |
11505-5 Physician procedure note
Part Descriptions
LP74249-1 Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD Procedure note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38946-6 | Physician| |
| LG38811-2 | Procedure note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de procedimiento: |
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: verslag procedure |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
28616-1 Physician Transfer note
Part Descriptions
LP73546-1 Transfer summary note
Transfer summary notes are generated by the originating institution. The setting (when specified) is the facility the patient is being transferred out of (not where they are going).
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Transfer summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD Transfer sum note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Change Reason
- Updated Component from "Transfer summarization note" to harmonize terms within the existing Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38946-6 | Physician| |
| LG38744-5 | Transfer summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Transferbericht: Synonyms: Bericht Transferbericht |
| es-AR | Spanish (Argentina) | TRANSFER SUMMARIZATION NOTE: |
| es-MX | Spanish (Mexico) | Transferir nota de resumen: |
| it-IT | Italian (Italy) | Traferimento, nota di sintesi: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | samenvatting van overdracht: |
| pt-BR | Portuguese (Brazil) | Anotação resumo de transferência: Synonyms: ; |
| zh-CN | Chinese (China) | 移交摘要记录: Synonyms: 临床文档型; |
28569-2 Consultant Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Consultant
Additional Names
- Short Name
- Consultant Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Changed Method from 'Consulting physician' to 'Physician consulting'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values. Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also canged class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Changed Method from "Physician consulting" to 'Consultant' based on Clinical LOINC Committee approval at 10/2018 meeting to remove "Physician" from Role values that could be used for non-physician specialities.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39015-9 | Consultant| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18763-3 Consultant Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Consultant
Additional Names
- Short Name
- Consultant Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.65
- Change Reason
- Changed Method from 'Consulting physician' to 'Physician consulting'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values.; Changed Method from "Physician consulting" to 'Consultant' based on Clinical LOINC Committee approval at 10/2018 meeting to remove "Physician" from Role values that could be used across non-physician type specialities.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39015-9 | Consultant| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
18737-7 Podiatry Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Podiatry
Additional Names
- Short Name
- Podiatry Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38949-0 | Podiatry| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28624-5 Podiatry Operation note
Part Descriptions
LP73465-4 Surgical operation note
Surgical operation note (Operative note) is note or report created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnoses, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report provides details to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Podiatry
Additional Names
- Short Name
- Podiatry Operative note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38949-0 | Podiatry| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de intervención quirúrgica: |
| es-MX | Spanish (Mexico) | Nota de operación quirúrgica: |
| fr-BE | French (Belgium) | Note opération chirurgicale.: |
| it-IT | Italian (Italy) | Nota di operazione chirurgica: Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | operatieverslag: |
| pt-BR | Portuguese (Brazil) | Anotação de cirurgia: Synonyms: ; |
| zh-CN | Chinese (China) | 外科手术记录: Synonyms: 临床文档型; |
28625-2 Podiatry procedure note
Part Descriptions
LP74249-1 Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Podiatry
Additional Names
- Short Name
- Podiatry Procedure note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38949-0 | Podiatry| |
| LG38811-2 | Procedure note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de procedimiento: |
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| fr-BE | French (Belgium) | Note de procédure: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: verslag procedure |
| pt-BR | Portuguese (Brazil) | Anotação de procedimento: Synonyms: Finding; |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
11509-7 Podiatry Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Podiatry
Additional Names
- Short Name
- Podiatry Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38949-0 | Podiatry| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
11488-4 Consult note
Part Descriptions
LP72311-1 Consultation note
A consultation note is generated by a provider upon request for an opinion or advice from another provider. Consultations may involve face-to-face time with the patient, telemedicine visits, or a second opinion on a diagnosis that does not involve interaction with a patient. A consultation note is typically sent to the referring provider when the consultation is completed.
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Consultation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Consult note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Previous Releases: Edit made because this term is conformant to the Document Ontology axis values and therefore are being placed in this class.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 9056
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38750-2 | Consultation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Befund: Synonyms: Bericht |
| es-MX | Spanish (Mexico) | Nota de consulta: |
| es-AR | Spanish (Argentina) | nota de consulta: |
| it-IT | Italian (Italy) | Nota di consulto: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | consultverslag: Synonyms: consultatie-aantekening |
| zh-CN | Chinese (China) | 会诊记录: Synonyms: 临床文档型; |
15507-7 Emergency department Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- Emergency department
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- ED Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0k
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41825-7 | Emergency department| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de progreso: |
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: Synonyms: SEH |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
11492-6 Provider-unspecifed, History and physical note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- History and physical note
- Property
- Find
- Time
- Pt
- System
- Hospital
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Hosp H&P note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 17187
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG38753-6 | History and physical note| |
| LG41829-9 | Hospital| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Historia y nota física: |
| es-AR | Spanish (Argentina) | HISTORY & PHYSICAL NOTE: |
| it-IT | Italian (Italy) | Anamnesi e visita medica: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | verslag voorgeschiedenis en lichamelijk onderzoek: |
| zh-CN | Chinese (China) | 病史与体格检查记录: Synonyms: 临床文档型; |
18842-5 Discharge summary
Part Descriptions
LP72467-1 Discharge summary note
Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition and disposition at discharge, information provided to the patient and family, and provisions for follow-up care.
Source: HL7
Fully-Specified Name
- Component
- Discharge summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- D/C sum
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.73
- Change Reason
- Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class. Changed Component from 'Discharge summarization note' per the Clinical LOINC Committee decision to harmonize existing terms in the LOINC Document Ontology.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 5023
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38746-0 | Discharge summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Entlassungsbrief Ärztlich: Synonyms: Bericht Entlassungsbrief aus stationärer Behandlung (Arzt); |
| es-MX | Spanish (Mexico) | Nota de resumen de alta: |
| es-AR | Spanish (Argentina) | nota de resumen en el momento del alta: |
| it-IT | Italian (Italy) | Lettera di dimissione ospedaliera: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | samenvattende ontslagbrief: |
| pt-BR | Portuguese (Brazil) | Anotação resumo de alta médica: Synonyms: ; |
| zh-CN | Chinese (China) | 出院摘要记录: Synonyms: 临床文档型; |
28636-9 Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Change Reason
- Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11504-8 Surgical operation note
Part Descriptions
LP73465-4 Surgical operation note
Surgical operation note (Operative note) is note or report created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnoses, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report provides details to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Operative note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Operationsbericht: Synonyms: Bericht OP-Bericht |
| es-MX | Spanish (Mexico) | Nota de operación quirúrgica: |
| es-AR | Spanish (Argentina) | nota de intervención quirúrgica: |
| it-IT | Italian (Italy) | Nota di operazione chirurgica: Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | operatieverslag: |
| zh-CN | Chinese (China) | 外科手术记录: Synonyms: 临床文档型; |
28570-0 Procedure note
Part Descriptions
LP74249-1 Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Procedure note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Change Reason
- Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 93340-8 | PhenX - complete blood count protocol 220501 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38811-2 | Procedure note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de procedimiento: |
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: verslag procedure |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
11506-3 Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class. Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de progreso: |
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18761-7 Transfer summary note
Part Descriptions
LP73546-1 Transfer summary note
Transfer summary notes are generated by the originating institution. The setting (when specified) is the facility the patient is being transferred out of (not where they are going).
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Transfer summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Transfer sum note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.58
- Change Reason
- Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class. Updated Component from "Transfer summarization note" to harmonize terms within the existing Document Ontology.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38744-5 | Transfer summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Transferbericht: Synonyms: Bericht Transferbericht |
| es-MX | Spanish (Mexico) | Transferir nota de resumen: |
| es-AR | Spanish (Argentina) | TRANSFER SUMMARIZATION NOTE: |
| it-IT | Italian (Italy) | Traferimento, nota di sintesi: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | samenvatting van overdracht: |
| zh-CN | Chinese (China) | 移交摘要记录: Synonyms: 临床文档型; |
28635-1 Psychiatry Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychiatry
Additional Names
- Short Name
- Psychiatric Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38973-0 | Psychiatry| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28627-8 Psychiatry Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychiatry
Additional Names
- Short Name
- Psychiatric Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG38973-0 | Psychiatry| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| pt-BR | Portuguese (Brazil) | Anotação de avaliação subsequente: Synonyms: ; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
11527-9 Psychiatry study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Psychiatry study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
- Psychiatry
Additional Names
- Short Name
- Psychiatry study
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Updated to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Psichiatria, studio: Synonyms: Clinico Osservazione paziente Punto nel tempo (episodio) Studio di psichiatria |
| nl-NL | Dutch (Netherlands) | psychiatrisch onderzoek: |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 精神病学检查: Synonyms: 临床文档型; |
28628-6 Psychiatry Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychiatry
Additional Names
- Short Name
- Psychiatric Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.52
- Change Reason
- Component was changed from 'Visit note' to 'Note', systerm was changed from ^Patient to {setting} and class was changed from ATTACH.CLINRPT to DOC.CLINRPT based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that 'Occupational therapy visit note', for example, is essentially the same as a 'Occupational therapy note'. Other parts of term were changed to correspond with current document ontology.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38973-0 | Psychiatry| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Befund: Synonyms: Bericht Psychiatrie |
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: |
| pt-BR | Portuguese (Brazil) | Anotação de visita: Synonyms: Finding; |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
18738-5 Psychology Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychology
Additional Names
- Short Name
- Psych Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38950-8 | Psychology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11510-5 Psychology Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychology
Additional Names
- Short Name
- Psych Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG38950-8 | Psychology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de progreso: |
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18739-3 Social worker Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Social worker
Additional Names
- Short Name
- SW Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.65
- Change Reason
- Changed Method from "Social work" to "Social worker" based on the Clinical LOINC Committee decision (10/2018) to represent Social work/er as a Role value in the LOINC Document Ontology.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38995-3 | Social worker| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28653-4 Social worker Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Social worker
Additional Names
- Short Name
- SW Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Component was changed from 'Visit note' to 'Note' and method was changed from 'Social service' to 'Social work'. Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits based on Clinical LOINC Committee approval at 8/16/2011 meeting to harmonize existing terms with Document Ontology values.; Changed Method from "Social work" to "Social worker" based on the Clinical LOINC Committee decision (10/2018) to represent Social work/er as a Role value in the LOINC Document Ontology.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 6253
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38995-3 | Social worker| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
28656-7 Social worker Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Social worker
Additional Names
- Short Name
- SW Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Changed Method from "Social work" to "Social worker" based on the Clinical LOINC Committee decision (10/2018) to represent Social work/er as a Role value in the LOINC Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG38995-3 | Social worker| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18740-1 Speech-language pathology Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Speech-language pathology
Additional Names
- Short Name
- Speech-lang path Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38951-6 | Speech-language pathology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: Synonyms: Anatomo-pathologie |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11512-1 Speech-language pathology Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Speech-language pathology
Additional Names
- Short Name
- Speech-lang path Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG38951-6 | Speech-language pathology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: Synonyms: Anatomo-pathologie |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28571-8 Speech-language pathology Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Speech-language pathology
Additional Names
- Short Name
- Speech-lang path Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Change Reason
- Component was changed from 'Visit note' to 'Note' based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that Occupational therapy visit note, for example, is essentially the same as a Occupational therapy note.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38951-6 | Speech-language pathology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: Synonyms: Anatomo-pathologie |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
27899-4 Diagnostic studies.non-lab (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Diagnostic studies.non lab
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.27
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios diagnósticos.sin laboratorio: |
| it-IT | Italian (Italy) | Studi diagnostici.non di laboratorio: Synonyms: Allegato Allegato referto clinico Complesso paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Диагностические исследования.не лабораторный: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 诊断性检查.非实验室: Synonyms: 临床信息附件集; |
26441-6 Cardiology studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Cardiology studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CARD
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.00
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios cardiológicos: |
| it-IT | Italian (Italy) | Studi di cardiologia: Synonyms: Allegato Allegato cardiaco Complesso paziente Stabilito; |
| pt-BR | Portuguese (Brazil) | Estudos de cardiologia: Synonyms: Complex |
| ru-RU | Russian (Russian Federation) | Кардиология исследования: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 心脏病学检查: Synonyms: Health Insurance Portability and Accountability Act of 1996; |
42148-7 US Heart
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Chest>Heart
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Hrt
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.16
- Last Updated
- Version 2.73
- Change Reason
- Changed Class from CARD.US to RAD and System from Heart to Chest>Heart to conform with LOINC/RadLex unified model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 4586
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41847-1 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Synonyms: Echokardiographie-Befund |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Cuore Eco Multistrato Osservazione Petto Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Seccionais: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
18745-0 Cardiac catheterization study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Cardiac catheterization study
- Property
- Find
- Time
- Pt
- System
- Heart
- Scale
- Doc
- Method
- Cardiac catheterization
Additional Names
- Short Name
- Cardiac catheterization study
Basic Attributes
- Class
- CARD.PROC
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Cateterizzazione cardiaca, studio: Synonyms: Osservazione Procedure cardiache Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 心脏导管插入术检查: Synonyms: 临床文档型; |
11524-6 EKG study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- EKG study
- Property
- Find
- Time
- Pt
- System
- Heart
- Scale
- Doc
- Method
- EKG
Additional Names
- Short Name
- EKG study
Basic Attributes
- Class
- CARD.PROC
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: CLASS: Assigned more representative Class for this concept.; COMPONENT: Updated to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 62397-5 | PhenX - myocardial infarct protocol 040801 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | ECG, studio: Synonyms: Elettrocardiogramma (ECG) Osservazione Procedure cardiache Punto nel tempo (episodio) Sudio ECG |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 心电图检查: Synonyms: EKG 临床文档型; |
18750-0 Cardiac electrophysiology study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Cardiac electrophysiology study
- Property
- Find
- Time
- Pt
- System
- Heart
- Scale
- Doc
- Method
- Electrophysiology
Additional Names
- Short Name
- Card Electrophysiology study
Basic Attributes
- Class
- CARD.PROC
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Update naming convention for studies.;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Elettrofisiologia cardiaca, studio: Synonyms: Osservazione Procedure cardiache Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 心脏电生理学检查: Synonyms: 临床文档型; |
18752-6 Exercise stress test study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Exercise stress test study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Exercise stress test study
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.70: SYSTEM: Updated for consistency across terms.; METHOD_TYP: Updated for consistency across terms.; COMPONENT: Updated for consistency across terms.;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe del estudio de la prueba de esfuerzo con ejercicio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Prova da sforzo, studio: Synonyms: Clinico Osservazione paziente Punto nel tempo (episodio) Studio di prova da sforzo |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 运动应激试验检查: Synonyms: 临床文档型; |
18754-2 Ambulatory cardiac rhythm monitor (Holter) study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Ambulatory cardiac rhythm monitor study
- Property
- Find
- Time
- Pt
- System
- Heart
- Scale
- Doc
- Method
- Holter monitor
Additional Names
- Short Name
- Holter monitor study
Basic Attributes
- Class
- CARD.PROC
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Update naming convention for studies.;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Ritmo cardicaco ambulatoriale, studio di monitoraggio: Synonyms: Holter Osservazione Procedure cardiache Punto nel tempo (episodio) Studio di monitoraggio del ritmo cardicaco ambulatoriale |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 动态心律监测仪检查: Synonyms: 24小时动态心电图监测仪; |
27895-2 Gastroenterology endoscopy studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Gastroenterology endoscopy studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.GI
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.00
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios endoscópicos gastroenterológicos: |
| it-IT | Italian (Italy) | Studi di gastroenterologia-endoscopia: Synonyms: Allegato Allegato gastrointestinale Complesso Gastrointestinale paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Гастроэнтерология эндоскопические исследования: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 胃肠道内镜检查: Synonyms: Health Insurance Portability and Accountability Act of 1996; |
28028-9 Anoscopy study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Anoscopy study
- Property
- Find
- Time
- Pt
- System
- Anus
- Scale
- Doc
- Method
- Anoscopy
Additional Names
- Short Name
- Anoscopy study
Basic Attributes
- Class
- ENDO.GI
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Updated to align with the current LOINC naming model for concepts representing studies.;
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | STUDY OBSERVATION: |
| es-MX | Spanish (Mexico) | Observación del estudio: |
| it-IT | Italian (Italy) | Anoscopia, studio: Synonyms: Endoscopia gastrointestinale Gastrointestinale Osservazione Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Observação: Synonyms: Finding; |
| zh-CN | Chinese (China) | 肛门镜检查: Synonyms: 临床文档型; |
18746-8 Colonoscopy study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Colonoscopy study
- Property
- Find
- Time
- Pt
- System
- Lower GI tract
- Scale
- Doc
- Method
- Colonoscopy
Additional Names
- Short Name
- Colonoscopy study
Basic Attributes
- Class
- ENDO.GI
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.73
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 16589
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe: |
| it-IT | Italian (Italy) | Colonscopia, studio: Synonyms: Colonscopia; |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 结肠镜检查: Synonyms: 下 下的 下部 临床文档型; |
28016-4 ERCP study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- ERCP study
- Property
- Find
- Time
- Stdy
- System
- Liver+Pancreas
- Scale
- Doc
- Method
- ERCP
Additional Names
- Short Name
- ERCP study
Basic Attributes
- Class
- ENDO.GI
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Update naming convention for studies.;
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | STUDY OBSERVATION: |
| es-MX | Spanish (Mexico) | Observación del estudio: |
| it-IT | Italian (Italy) | CPRE, studio: Synonyms: Colangiopancreatografia retrograda endoscopica (CP Endoscopia gastrointestinale Fegato e Pancreas Gastrointestinale Osservazione |
| pt-BR | Portuguese (Brazil) | Observação: Synonyms: Finding; |
| zh-CN | Chinese (China) | 经内镜逆行胆胰管成像检查: Synonyms: 临床文档型; |
18751-8 Endoscopy study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Endoscopy study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
- Endoscopy
Additional Names
- Short Name
- Endoscopy study
Basic Attributes
- Class
- ENDO.GI
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Update to reflect current naming convention for studies; Release 2.68: SYSTEM: Updated to align with the LOINC clinical document model where the System represents the Setting. Since an endoscopy study can take place in various clinical settings (outpatient, inpatient, etc.), the Setting is unspecified ({Setting}).
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Endoscopia, studio: Synonyms: Endoscopia gastrointestinale Gastrointestinale Osservazione paziente Punto nel tempo (episodio) Studio endoscopico |
| nl-NL | Dutch (Netherlands) | endoscopisch onderzoek: Synonyms: endoscopie |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 内镜检查: Synonyms: 临床文档型; |
28018-0 Enteroscopy study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Enteroscopy study
- Property
- Find
- Time
- Stdy
- System
- Small bowel
- Scale
- Doc
- Method
- Enteroscopy
Additional Names
- Short Name
- Enteroscopy study
Basic Attributes
- Class
- ENDO.GI
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: SCALE_TYP: Model consistency for studies.; COMPONENT: Update naming convention for studies.;
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | STUDY OBSERVATION: |
| es-MX | Spanish (Mexico) | Observación del estudio: |
| it-IT | Italian (Italy) | Enteroscopia, studio: Synonyms: Endoscopia gastrointestinale Gastrointestinale Osservazione Studio Enteroscopia |
| pt-BR | Portuguese (Brazil) | Observação: Synonyms: Finding; |
| zh-CN | Chinese (China) | 肠镜检查: Synonyms: 临床文档型; |
18753-4 Flexible sigmoidoscopy study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Flexible sigmoidoscopy study
- Property
- Find
- Time
- Pt
- System
- Lower GI tract
- Scale
- Doc
- Method
- Flexible sigmoidoscopy
Additional Names
- Short Name
- Flex sigmoidoscopy study
Basic Attributes
- Class
- ENDO.GI
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Sigmoidoscopia flessibile, studio: Synonyms: Endoscopia gastrointestinale Gastrointestinale Osservazione Punto nel tempo (episodio) Tratto gastrointestinale inferiore |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 软乙状结肠镜检查: Synonyms: 下 下的 下部 临床文档型; |
27897-8 Neuromuscular electrophysiology studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Neuromuscular electrophysiology studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.00
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios electrofisiológicos neuromusculares: |
| it-IT | Italian (Italy) | Studi di elettrofisiologia neuromuscolare: Synonyms: Allegato Complesso paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Нейромышечные электрофизиологические исследования: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 神经肌肉电生理学检查: Synonyms: 临床信息附件集; |
11523-8 EEG study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Electroencephalography study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- EEG study
Basic Attributes
- Class
- NEURO
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Update naming convention for studies.; Previous Releases: Updated Component from "Study report", System from "Brain", and Method from "EEG" to align with LOINC document model.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe del estudio de electroencefalografía: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Elettroencefalogramma, studio: Synonyms: Neurologia Osservazione paziente Punto nel tempo (episodio) Studio Elettroencefalogramma; |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 脑电图检查: Synonyms: 临床文档型; |
18749-2 Electromyogram study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Electromyogram study
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- Electromyogram
Additional Names
- Short Name
- Electromyogram study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: update to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Elettromiogramma, studio: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Studio Elettromiogramma |
| nl-NL | Dutch (Netherlands) | elektromyografisch onderzoek: Synonyms: elektromyogram EMG |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 肌电图检查: Synonyms: 不明的; |
29755-6 Nerve conduction study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Nerve conduction study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
- Nerve conduction
Additional Names
- Short Name
- Nerve conduction study
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe del estudio: |
| es-MX | Spanish (Mexico) | Informe de estudio: |
| it-IT | Italian (Italy) | Conduzione nervosa, studio: Synonyms: Clinico Osservazione paziente Punto nel tempo (episodio) Studio conduzione nervosa |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 神经传导检查: Synonyms: 临床文档型; |
29754-9 Nystagmogram study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Nystagmogram study
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- Nystagmogram
Additional Names
- Short Name
- Nystagmogram study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe del estudio: |
| es-MX | Spanish (Mexico) | Informe de estudio: |
| it-IT | Italian (Italy) | Nistagmogramma, studio: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Studio di nistagmogramma |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 眼震电图检查: Synonyms: 不明的; |
26442-4 Obstetrical studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Obstetrical studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.OBS
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.00
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios obstétricos: |
| it-IT | Italian (Italy) | Studi di ostetricia: Synonyms: Allegato Allegato ostetricia Complesso paziente Stabilito; |
| pt-BR | Portuguese (Brazil) | Estudos obstétricos: Synonyms: Complex |
| ru-RU | Russian (Russian Federation) | Акушерские исследования: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 产科学检查: Synonyms: Health Insurance Portability and Accountability Act of 1996; |
11525-3 US for pregnancy
Part Descriptions
LP175724-6 Multisection for pregnancy
Pregnancy ultrasound terms in LOINC reflect the structure of radiology order and billing codes for pregnancy. Therefore, "Multisection for pregnancy" is defined as imaging of the pelvis and a single fetus and "Multisection for pregnancy multiple gestation" is defined as imaging of the pelvis and an additional fetus. For example, for triplet pregnancies, imaging of the first fetus would be ordered and reported under the "Multisection for pregnancy" code, and imaging of the second and third fetus would be ordered and reported using two instances of the "Multisection for pregnancy multiple gestation" code. In addition, the codes can be further specified according to "first trimester" or "second or third trimester".
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection for pregnancy
- Property
- Find
- Time
- Pt
- System
- Pelvis+^Fetus
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US for pregnancy
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.67
- Change Reason
- Edited name to harmonize with LOINC radiology style where US (method) is the Modality and pregnancy is the Reason for exam. Changed System from "Pelvis+Fetus" to "Pelvis+^Fetus" to reflect the fetus as a super system.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41848-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Synonyms: Geburtshilfliche Ultraschalluntersuchung |
| es-MX | Spanish (Mexico) | Multisección para el embarazo: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Multisezione per gravidanza: Synonyms: Bacino Eco Multistrato Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 针对妊娠的多层: Synonyms: (多层（多平面、 |
28619-5 Ophthalmology/Optometry studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Ophthalmology studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.00
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios de oftalmología: |
| it-IT | Italian (Italy) | Studi di oftalmologia: Synonyms: Allegato Allegato referto clinico Complesso paziente Stabilito; |
| pt-BR | Portuguese (Brazil) | Estudos de Oftalmologia: Synonyms: Complex |
| ru-RU | Russian (Russian Federation) | Офтальмологические исследования: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 眼科学检查: Synonyms: 临床信息附件集; |
29268-0 Contact lens measurements
Term Description
Ophthalmology group
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Contact lens measurements
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Multi
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.03
- Last Updated
- Version 2.03
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | mediciones de lentes de contacto: |
| it-IT | Italian (Italy) | Misura lenti a contatto: Synonyms: Allegato Allegato referto clinico Osservazione paziente Punto nel tempo (episodio) |
| ru-RU | Russian (Russian Federation) | Контактные линзы измерения: Synonyms: Точка во времени; |
| zh-CN | Chinese (China) | 隐形眼镜测量指标: Synonyms: 临床报告信息附件; |
29269-8 Eye glasses measurements
Term Description
Ophthalmology group
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Eye glasses measurements
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Multi
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.03
- Last Updated
- Version 2.03
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | mediciones de anteojos: |
| it-IT | Italian (Italy) | Misurazioni occhiali: Synonyms: Allegato Allegato referto clinico Osservazione paziente Punto nel tempo (episodio) |
| ru-RU | Russian (Russian Federation) | Глаз очки измерения: Synonyms: Точка во времени; |
| zh-CN | Chinese (China) | 眼镜测量结果: Synonyms: 临床报告信息附件; |
29271-4 Eye physical examination
Term Description
Ophthalmology group includes exopthalmia, convergence, eye position
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Eye physical examination
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Multi
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.03
- Last Updated
- Version 2.03
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | examen físico ocular: |
| it-IT | Italian (Italy) | Esame oculistico: Synonyms: Allegato Allegato referto clinico Osservazione paziente Punto nel tempo (episodio) |
| ru-RU | Russian (Russian Federation) | Глаз физикальное исследование: Synonyms: Точка во времени; |
| zh-CN | Chinese (China) | 眼部体格检查: Synonyms: 临床报告信息附件; |
29272-2 Eye ultrasound study
Term Description
Ophthalmology group for ultrasound studies related to the eye
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Eye ultrasound study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Eye ultrasound study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudio ecográfico ocular: |
| es-MX | Spanish (Mexico) | Estudio de ultrasonido ocular: |
| it-IT | Italian (Italy) | Studio ecografico oculare: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
| ru-RU | Russian (Russian Federation) | Глаз ультразвуковое исследование: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 眼部超声检查: Synonyms: 临床文档型; |
28632-8 Heterophoria study
Term Description
A tendency for deviation of the eyes from parallelism, prevented by binocular vision.
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Heterophoria study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Heterophoria study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | heteroforia estudio: |
| es-MX | Spanish (Mexico) | Estudio de heterophoria: |
| it-IT | Italian (Italy) | Studio di eteroforia: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Estudo de Heteroforia: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Гетерофория исследование: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 隐斜视检查: Synonyms: 临床文档型; |
28629-4 Perimetry study
Term Description
A perimetry study involves the systematic measurement of visual field function. The test is performed to detect abnormalities in the patient's central and peripheral vision caused by various medical conditions, including stroke, glaucoma, brain tumors or other neurological deficits. PMID: 21131878
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Perimetry study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Perimetry study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.67
- Change Reason
- Added term description.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- No IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudio de perímetro: |
| es-MX | Spanish (Mexico) | Estudio de perimetría: |
| it-IT | Italian (Italy) | Perimetria: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Estudo de Perimetria: Synonyms: Visual field testing; |
| ru-RU | Russian (Russian Federation) | Периметрия исследование: Synonyms: Документ Периметрическое исследование Точка во времени; |
| zh-CN | Chinese (China) | 视野测定法检查: Synonyms: 临床文档型; |
29270-6 Retinal treatments
Term Description
Ophthalmology group includes YAG and Argon Laser therapies
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Retinal treatments
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Multi
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.03
- Last Updated
- Version 2.03
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | tratamientos retinianos: |
| it-IT | Italian (Italy) | Trattamenti retinici: Synonyms: Allegato Allegato referto clinico Cure retiniche Osservazione paziente Punto nel tempo (episodio) |
| ru-RU | Russian (Russian Federation) | Сетчатка лечение: Synonyms: Точка во времени; |
| zh-CN | Chinese (China) | 视网膜治疗: Synonyms: 临床报告信息附件; |
28630-2 Tonometry study
Part Descriptions
LP76227-5 Tonometry
Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine the IOP. IOP is an important aspect in the evaluation of patients at risk for glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg).
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Tonometry study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Tonometry study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudio de tonometría: |
| es-MX | Spanish (Mexico) | Estudio de tonometría: |
| it-IT | Italian (Italy) | Studio di tonometria: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Estudo de Tonometria: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Тонометрия исследование: Synonyms: Документ Тонометрия; |
| zh-CN | Chinese (China) | 眼压测量检查: Synonyms: 临床文档型; |
28631-0 Visual acuity study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Visual acuity study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Visual acuity study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
| 70947-7 | General eye evaluation |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudio de la agudeza visual: |
| es-MX | Spanish (Mexico) | Estudio de agudeza visual: |
| it-IT | Italian (Italy) | Studio di acuità visiv: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Estudo de Acuidade Visual: Synonyms: Refraction; |
| ru-RU | Russian (Russian Federation) | Зрение острота исследование: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 视力检查: Synonyms: 临床文档型; |
27898-6 Pathology studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Pathology studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.LAB
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Common Test Rank Get Info
- 19601
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios patológicos: |
| fr-FR | French (France) | Pathologie: |
| it-IT | Italian (Italy) | Studi di patologia: Synonyms: Allegato Allegato di laboratorio Complesso paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Патология исследования: Synonyms: Комплекс Патологоанатомические исследования |
| zh-CN | Chinese (China) | 病理学检查: Synonyms: Health Insurance Portability and Accountability Act of 1996; |
18743-5 Autopsy report
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Autopsy report
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Autopsy report
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 6405
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Obduktionsbefund: |
| es-MX | Spanish (Mexico) | Informe de autopsia: |
| es-AR | Spanish (Argentina) | nota de autopsia: |
| fr-CA | French (Canada) | Rapport d'autopsie: Synonyms: #REF! |
| it-IT | Italian (Italy) | Autopsia, referto: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Referto Referto dell''autopsia Ruolo non specificato |
| pt-BR | Portuguese (Brazil) | Anotação de autópsia: Synonyms: Finding; |
| uk-UA | Ukrainian (Ukraine) | Звіт про аутопсію: Synonyms: DOC.ONT; |
| zh-CN | Chinese (China) | 尸体解剖报告: Synonyms: 临床文档型; |
11526-1 Pathology study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Pathology study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
- Pathology
Additional Names
- Short Name
- Pathology study
- Display Name
- Pathology study
- Consumer Name Alpha Get Info
- Pathology study
Basic Attributes
- Class
- PATH
- Type
- Laboratory
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Release 2.72: COMPONENT: Update naming convention for studies.; CLASS: Assigned a more greater specification for Class.;
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 618
- HL7® Attachment Structure
- No IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| fr-CA | French (Canada) | Étude de pathologie: |
| it-IT | Italian (Italy) | Studio di patologia: Synonyms: Osservazione Patologia paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | pathologisch onderzoek: |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 病理学检查: Synonyms: 临床文档型; |
11529-5 Surgical pathology study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical pathology study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
- Surgical pathology
Additional Names
- Short Name
- Surgical pathology study
- Display Name
- Surgical pathology study
- Consumer Name Alpha Get Info
- Surgical pathology study
Basic Attributes
- Class
- PANEL.MISC
- Type
- Laboratory
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.75
- Change Reason
- Release 2.75: PanelType: Missing panel type; CLASS: Incorrect class; Release 2.72: COMPONENT: Update naming convention for studies.; CLASS: Greater specification.;
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 384
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 60567-5 | Comprehensive pathology report panel |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-ES | Spanish (Spain) | Estudio de patología quirúrgica.: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Studio di patologia chirurgica: Synonyms: Miscellanea Osservazione paziente Punto nel tempo (episodio) Set di prescrizione miscellanea |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 外科病理学检查: Synonyms: 临床文档型; |
27896-0 Pulmonary studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Pulmonary studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.RESP
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.02
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios pulmonares: |
| it-IT | Italian (Italy) | Studi polmonari: Synonyms: Allegato Allegato respiratorio Complesso paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Лёгких исследования: Synonyms: Исследования лёгких Комплекс |
| zh-CN | Chinese (China) | 肺部检查: Synonyms: HIPAA 信息附件.呼吸系统临床报告; |
18744-3 Bronchoscopy study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Bronchoscopy study
- Property
- Find
- Time
- Pt
- System
- Respiratory system
- Scale
- Doc
- Method
- Bronchoscopy
Additional Names
- Short Name
- Bronchoscopy study
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Broncoscopia, studio: Synonyms: Clinico Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | bronchoscopisch onderzoek: Synonyms: bronchoscopie systema respiratorium; |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 支气管镜检查: Synonyms: 临床文档型; |
28633-6 Polysomnography (sleep) study
Term Description
Polysomnography (PSG) is a type of sleep study used to diagnose, rule out, or adjust treatment for sleep disorders such as obstructive sleep apnea (OSA), narcolepsy, periodic limb movements, and REM behavior disorder. A sleep study measures sleep cycles and stages by monitoring biophysiological changes that occur during sleep. These changes are recorded using electrodes attached to the patient. Some of the parameters measured are: air flow in and out of the lungs, blood oxygen levels, body position, brain waves using an electroencephalogram (EEG), breathing effort and rate, electrical activity of the muscles using electromyogram (EMG), eye movement using electrooculogram (EOG), and heart rhythm using an electrocardiogram (ECG). Sleep studies track how often the patient stops breathing for at least 10 seconds (apnea) and how often breathing is partly blocked for 10 seconds (hypopnea). Results reported include the Apnea-Hypopnea Index (AHI). An AHI of less than 5 is considered normal. Normal results would also include normal patterns for brain waves and muscle movement.
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Polysomnography study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
- Polysomnography
Additional Names
- Short Name
- Polysomnography study
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
- HL7® Attachment Structure
- No IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe del estudio: |
| es-MX | Spanish (Mexico) | Informe de estudio: |
| it-IT | Italian (Italy) | Polisonnografia, studio: Synonyms: Clinico Osservazione paziente Punto nel tempo (episodio) Studio di polisonnografia |
| nl-NL | Dutch (Netherlands) | polysomnografisch onderzoek: Synonyms: PSG |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多导睡眠脑电图检查: Synonyms: Sleep apnea syndrome; |
18759-1 Spirometry study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Polysomnography study
- Property
- Find
- Time
- Pt
- System
- Respiratory system
- Scale
- Doc
- Method
- Spirometry
Additional Names
- Short Name
- Spirometry study
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
| 81458-2 | Pulmonary function test panel |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Polisonnografia, studio: Synonyms: Clinico Osservazione Punto nel tempo (episodio) Studio di polisonnografia |
| nl-NL | Dutch (Netherlands) | polysomnografisch onderzoek: Synonyms: systema respiratorium; |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多导睡眠脑电图检查: Synonyms: 临床文档型; |
18726-0 Radiology studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Radiology studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 1.0l
- Last Updated
- Version 2.27
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-DE | German (Germany) | Radiologische Untersuchungen: |
| es-AR | Spanish (Argentina) | estudios radiológicos: |
| it-IT | Italian (Italy) | Studi di radiologia: Synonyms: Allegato Allegato referto clinico Complesso paziente Stabilito; |
| ru-RU | Russian (Russian Federation) | Радиологические исследования: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 放射医学检查: Synonyms: X光线学 X光线科 X射线学 临床信息附件集; |
18748-4 Diagnostic imaging study
Fully-Specified Name
- Component
- Diagnostic imaging study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
- Diagnostic imaging
Additional Names
- Short Name
- Diagnostic imaging study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Update naming convention for studies.; SYSTEM: Update model.; CLASS: Greater specification.;
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-DE | German (Germany) | Diagnostische Bildgebung - Untersuchung: |
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe: |
| it-IT | Italian (Italy) | Diagnostica per immagini, studio: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) Studio di diagnostica per immagini |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 诊断成像检查: Synonyms: 临床文档型; |
18782-3 X-ray unspecified site study
Term Description
Radiology study observation (or Findings) contains the main narrative body of a radiology report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines for the codes in the various observations and procedures recorded in this section.
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Study observation
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Nar
- Method
- Radiology
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 1.0l
- Last Updated
- Version 2.63
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
| 85430-7 | Diagnostic imaging report - example sections and entries |
| 72230-6 | Diagnostic imaging report - recommended C-CDA R1.1 sections |
| 81220-6 | Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Untersuchung: Synonyms: Befund |
| es-AR | Spanish (Argentina) | STUDY OBSERVATION: |
| it-IT | Italian (Italy) | Rilievo: Synonyms: Allegato Allegato referto clinico Osservazione Osservazione di studio Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | observatieonderzoek: |
| pt-BR | Portuguese (Brazil) | Observação: Synonyms: Finding; |
| zh-CN | Chinese (China) | 检查观察结果: Synonyms: 不明的; |
28564-3 X-ray head study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Head>Skull
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Skull Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Skull" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 9697
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41824-0 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Cranio Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
28613-8 X-ray spine unspecified study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- XXX>Spine
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Spine Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model. Changed System from "Spine" to "XXX>Spine" for conformance with the LOINC/Radlex unified model.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Colonna vertebrale Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24946-6 X-ray spine cervical study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Neck>Spine.cervical
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR C-spine Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Spine.cervical" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41846-3 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Colonna vertebrale Cervicale Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24983-9 X-ray spine thoracic study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Chest>Spine.thoracic
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR T-spine Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Spine.thoracic" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41847-1 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Colonna vertebrale Toracica Osservazione Petto Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: CXR Films; |
24972-2 X-ray spine lumbar study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Abdomen>Spine.lumbar
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR L-spine Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Spine.lumbar" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41823-2 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Addome e Colonna vertebrale lombare Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24762-7 X-ray hip study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Lower extremity>Hip
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Hip Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Hip" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41849-7 | Region imaged: |
| LG37807-1 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Anca Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
28561-9 X-ray pelvis study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Pelvis
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Pelvis Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 5598
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41848-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Bacino Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| ru-RU | Russian (Russian Federation) | Проекции: Synonyms: Документ Изображения; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24704-9 X-ray femur study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Lower extremity>Femur
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Femur Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Femur" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 10910
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41849-7 | Region imaged: |
| LG37804-8 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Puntos de vista: |
| es-AR | Spanish (Argentina) | proyecciones: |
| it-IT | Italian (Italy) | Viste: Synonyms: Femore Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
28565-0 X-ray knee study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Lower extremity>Knee
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Knee Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Knee" to conform with LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 5116
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41849-7 | Region imaged: |
| LG37817-0 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Ginocchio Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
25011-8 X-ray tibia and fibula study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Lower extremity>Tibia+Fibula
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Tib+Fib Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Tibia+Fibula" per LOINC/RadLex unified model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 7420
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41849-7 | Region imaged: |
| LG37771-9 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Osservazione Punto nel tempo (episodio) Radiologia Raggi X Tibia e Perone |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| ru-RU | Russian (Russian Federation) | Проекции: Synonyms: Документ Изображения; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24541-5 X-ray ankle study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Lower extremity>Ankle
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Ankle Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Ankle" per the LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41849-7 | Region imaged: |
| LG37794-1 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Caviglia Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24709-8 X-ray foot study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Lower extremity>Foot
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Foot Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Foot" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41849-7 | Region imaged: |
| LG37806-3 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24909-4 X-ray shoulder study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Upper extremity>Shoulder
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Should Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Changed System from "Shoulder" per LOINC/Radlex unified model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 2741
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41850-5 | Region imaged: |
| LG37767-7 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Osservazione Punto nel tempo (episodio) Radiologia Raggi X Spalla |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
28567-6 X-ray humerus study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Upper extremity>Humerus
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Humerus Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Humerus" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 7861
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41850-5 | Region imaged: |
| LG37818-8 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Omero Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| ru-RU | Russian (Russian Federation) | Проекции: Synonyms: Документ Изображения; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24891-4 X-ray radius and ulna study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Upper extremity>Radius+Ulna
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Radius+Ulna Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Radius+Ulna" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41850-5 | Region imaged: |
| LG37762-8 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Osservazione Punto nel tempo (episodio) Radio Radio e Ulna Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| ru-RU | Russian (Russian Federation) | Проекции: Synonyms: Документ Изображения; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24676-9 X-ray elbow study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Upper extremity>Elbow
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Elbow Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Elbow" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41850-5 | Region imaged: |
| LG37803-0 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Puntos de vista: |
| es-AR | Spanish (Argentina) | proyecciones: |
| it-IT | Italian (Italy) | Viste: Synonyms: Gomito Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
24619-9 X-ray wrist study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Upper extremity>Wrist
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Wrist Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Wrist" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41850-5 | Region imaged: |
| LG37808-9 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Puntos de vista: |
| es-AR | Spanish (Argentina) | proyecciones: |
| it-IT | Italian (Italy) | Viste: Synonyms: Osservazione Polso Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
28582-5 X-ray hand study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views
- Property
- Find
- Time
- Pt
- System
- Upper extremity>Hand
- Scale
- Doc
- Method
- XR
Additional Names
- Short Name
- XR Hand Views
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Hand" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41850-5 | Region imaged: |
| LG37819-6 | XR| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Puntos de vista: |
| it-IT | Italian (Italy) | Viste: Synonyms: Mano Osservazione Punto nel tempo (episodio) Radiologia Raggi X |
| pt-BR | Portuguese (Brazil) | Incidências: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图: Synonyms: Films; |
25045-6 CT Unspecified body region
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Unsp region
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Multisection: Synonyms: CT |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24725-4 CT Head
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Head
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Head
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 7770
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41824-0 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
28566-8 CT spine study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- XXX>Spine
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Spine
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model. Changed System from "Spine" to "XXX>Spine" for conformance with the LOINC/Radlex unified model.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Colonna vertebrale Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24932-6 CT spine cervical study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Neck>Spine.cervical
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT C-spine
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Spine.cervical" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 9045
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41846-3 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Colonna vertebrale Cervicale Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24978-9 CT spine thoracic study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Chest>Spine.thoracic
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT T-spine
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Spine.thoracic" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 10982
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41847-1 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Colonna vertebrale Toracica Multistrato Osservazione Petto Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24963-1 CT spine lumbar study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Abdomen>Spine.lumbar
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT L-spine
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Updated System from "Spine.lumbar" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 8287
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41823-2 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Addome e Colonna vertebrale lombare Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24627-2 CT Chest
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Chest
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Chest
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 3726
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41847-1 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Multistrato Osservazione Petto Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
41806-1 CT Abdomen
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Abdomen
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Abd
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.16
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 8759
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41823-2 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Addome e Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24866-6 CT pelvis study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection^W contrast IV
- Property
- Find
- Time
- Pt
- System
- Pelvis
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Pelvis W contr IV
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 6504
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41848-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [multisección - tomas múltiples]^con contraste.XXX intravenoso: |
| es-MX | Spanish (Mexico) | Multisección ^ W contraste IV: |
| it-IT | Italian (Italy) | Sezioni multiple^Con contrasto EV: Synonyms: Bacino Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes^com contraste EV: Synonyms: ; |
| zh-CN | Chinese (China) | 多层^采用静脉注射对比剂: Synonyms: (多层（多平面、 |
24690-0 CT extremity study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Extremity
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Extr
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 16381
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG40818-3 | CT| |
| LG41851-3 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
25056-3 MR Unspecified body region
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Unsp region
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Synonyms: Magnetresonanztomographie-Befund |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
42698-1 MRI spine study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Neck>Spine.cervical & Chest>Spine.thoracic & Abdomen>Spine.lumbar
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR C+T+L-spine
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.16
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Updated System from "Spine.cervical+Spine.thoracic+Spine.lumbar" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41823-2 | Region imaged: |
| LG41847-1 | Region imaged: |
| LG41846-3 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Addome e Colonna vertebrale cervicale Colonna vertebrale cervicale e Colonna vertebrale toracica Colonna vertebrale cervicale e Colonna vertebrale toracica e Colonna vertebrale lombare Colonna vertebrale lombare Colonna vertebrale toracica Colonna vertebrale toracica e Colonna vertebrale l Multistrato Osservazione Petto Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24590-2 MR Brain
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Head>Brain
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Brain
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Changed System from "Brain" to "Head>Brain" for conformance with LOINC/RadLex unified model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 7626
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41824-0 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Cervello Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24935-9 MRI spine cervical study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Neck>Spine.cervical
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR C-spine
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Updated System from "Spine.cervical" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 6741
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41846-3 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Colonna vertebrale Cervicale Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24980-5 MRI spine thoracic study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Chest>Spine.thoracic
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR T-spine
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Updated System from "Spine.thoracic" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 5846
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41847-1 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Colonna vertebrale Toracica Multistrato Osservazione Petto Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24968-0 MRI spine lumbar study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Abdomen>Spine.lumbar
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR L-spine
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Updated System from "Spine.lumbar" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 5470
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41823-2 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Addome e Colonna vertebrale lombare Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24629-8 MRI chest study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Chest
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Chest
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41847-1 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Multistrato Osservazione Petto Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24556-3 MRI abdomen study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Abdomen
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Abd
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 11452
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41823-2 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Addome e Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24872-4 MRI pelvis and hips study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Pelvis & Lower extremity>Hip
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Pelvis and Hip
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier. Changed System from "Pelvis+Hip" to "Pelvis & Lower extremity>Hip" for conformance with the LOINC/RadLex unified model.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41849-7 | Region imaged: |
| LG41848-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Anca Bacino Multistrato Osservazione Pelvi e Anca Pelvi e Estremità inferiore Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24707-2 MRI foot study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Lower extremity>Foot
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Foot
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Updated System from "Foot" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG37780-0 | MR| |
| LG41849-7 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24710-6 MRI forearm study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Upper extremity>Forearm
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Forearm
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Added Region imaged per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG37781-8 | MR| |
| LG41850-5 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Avambraccio Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
28576-7 MRI joint study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- XXX>Joint
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Joint
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model. Changed system from xxx joint for conformance with LOINC/RadLex unified model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Updated System from "Joint" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Articolazione Articolazione XXX Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24720-5 MRI hand study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Upper extremity>Hand
- Scale
- Doc
- Method
- MR
Additional Names
- Short Name
- MR Hand
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "MRI" was changed to "MR". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Updated System from "Hand" per LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG37782-6 | MR| |
| LG41850-5 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Mano Multistrato Osservazione Punto nel tempo (episodio) Radiologia Risonanza magnetica per imaging (MRI) |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24605-8 Mammogram diagnostic views study
Part Descriptions
LP33575-9 Views diagnostic
Diagnostic mammography involves additional views of the breast beyond the two views typically taken with screening mammography. Diagnostic mammography is performed when a woman presents with breast changes (e.g. lumps, pain, nipple discharge, etc) or when an abnormality is detected on a screening mammogram.
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views diagnostic
- Property
- Find
- Time
- Pt
- System
- Breast
- Scale
- Doc
- Method
- MG
Additional Names
- Short Name
- MG Brst Dx
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "Mam" was changed to "MG". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 3121
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
| 94137-7 | HEDIS 2020 Value Sets |
| 96068-2 | HEDIS MY 2020 Value Sets |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG38542-3 | MG| |
| LG41854-7 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Vistas de diagnóstico: |
| es-AR | Spanish (Argentina) | mamografía: |
| it-IT | Italian (Italy) | Viste diagnostica: Synonyms: Mammografia Osservazione Petto Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Incidências para diagnóstico: Synonyms: ; |
| zh-CN | Chinese (China) | 诊断性多重视图: Synonyms: Films; |
24606-6 Mammogram screening views study
Part Descriptions
LP33645-0 Views screening
Screening mammography is used to look for breast changes in women without signs of breast cancer. Typically, screening mammography involves two views (craniocaudal and mediolateral oblique views) of each breast.
Source: Regenstrief LOINC
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views screening
- Property
- Find
- Time
- Pt
- System
- Breast
- Scale
- Doc
- Method
- MG
Additional Names
- Short Name
- MG Brst screening
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "Mam" was changed to "MG". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 3451
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
| 94137-7 | HEDIS 2020 Value Sets |
| 96068-2 | HEDIS MY 2020 Value Sets |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG38574-6 | MG| |
| LG41854-7 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Synonyms: Mammografie |
| es-AR | Spanish (Argentina) | mamografía: |
| es-MX | Spanish (Mexico) | Proyección de vistas: |
| it-IT | Italian (Italy) | Viste di screening: Synonyms: Mammografia Osservazione Petto Punto nel tempo (episodio) Radiologia Viste di controllo |
| pt-BR | Portuguese (Brazil) | Incidências para triagem: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图 筛查: Synonyms: Asympt Films; |
24888-0 Nuclear medicine pulmonary VQ scan study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views ventilation+perfusion^W Xe-133 IH+W Tc-99m MAA IV
- Property
- Find
- Time
- Pt
- System
- Chest>Pulmonary system
- Scale
- Doc
- Method
- NM
Additional Names
- Short Name
- NM Pulm system VP W 133Xe IH+Tc99mMAA IV
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model. Changed to align with the HL7 routes of administration.; Method of "Radnuc" was changed to "NM". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.; Updated "&" to "+" in Component and Challenge and added "Chest" as region imaged to match syntax used in LOINC/RadLex unified model.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41847-1 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones para ventilación y perfusión: |
| es-MX | Spanish (Mexico) | Vistas ventilación + perfusión ^W Xe-133 IH + W Tc-99m MAA IV: |
| it-IT | Italian (Italy) | Viste ventilazione+perfusione^Con Xe-133 inalato & con Tc-99m MAA EV: Synonyms: Apparato respiratorio Con Xe-133 inalato e con Tc-99m MAA EV Inalazione Osservazione Petto Punto nel tempo (episodio) Radiologia Viste ventilazione e perfusione |
| pt-BR | Portuguese (Brazil) | Imagens de ventilação e perfusão^com inalação de Xe-133 e Tc-99m MAA EV: Synonyms: ; |
| zh-CN | Chinese (China) | 多重视图 通气+灌注^采用吸入 Xe-133 +采用静脉注射 Tc-99m MAA: Synonyms: 133 Xe 133 氙 133氙 99 mTC 99mTc 99m锝 Films; |
30695-1 Nuclear medicine thyroid scan study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Views^W radionuclide IV
- Property
- Find
- Time
- Pt
- System
- Neck>Thyroid gland
- Scale
- Doc
- Method
- NM
Additional Names
- Short Name
- NM Thyroid Views W RNC IV
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.04
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model. Changed System from "Thyroid" for conformance with the LOINC/RadLex unified model.; Method of "Radnuc" was changed to "NM". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41846-3 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones^radioisótopos.endovenosos: |
| es-MX | Spanish (Mexico) | Vistas ^ W radionúclido IV: |
| it-IT | Italian (Italy) | Viste^Con radionuclide EV: Synonyms: Ghiandola tiroidea Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Imagens^com radionuclídeo EV: Synonyms: View; |
| zh-CN | Chinese (China) | 多重视图^采用静脉注射放射性核素: Synonyms: Films; |
44136-0 PT Unspecified body region
Fully-Specified Name
- Component
- Multisection^W radionuclide IV
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- PT
Additional Names
- Short Name
- PT W RNC IV
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.17
- Last Updated
- Version 2.69
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "Radnuc.PET" was changed to "PT". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier. Added "W radionuclide IV" per the LOINC model for including a generic tracer for nuclear medicine studies when a specific named tracer is not used.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Synonyms: Positronen-Emissions-Tomographie-Befund |
| es-MX | Spanish (Mexico) | Radionúclido IV de sección múltiple ^ W: |
| it-IT | Italian (Italy) | Sezioni multiple^Con radionuclide EV: Synonyms: Multistrato Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Multi cortes: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层^采用静脉注射放射性核素: Synonyms: (多层（多平面、 |
25043-1 CT guidance for aspiration of unspecified site study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Guidance for percutaneous aspiration of fluid
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Guided PC fluid asp
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Added "percutaneous" and "of fluid" to better define the Component per the LOINC/RadLex unified model
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | guía para aspiración: |
| es-MX | Spanish (Mexico) | Orientación para la aspiración percutánea de líquido: |
| it-IT | Italian (Italy) | Guida per aspirazione percutanea: Synonyms: Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Orientação para aspiração: Synonyms: ; |
| zh-CN | Chinese (China) | 旨在经皮穿刺抽吸的引导: Synonyms: CAT 扫描; |
25044-9 CT guidance for biopsy of unspecified site study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Guidance for percutaneous biopsy
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- CT
Additional Names
- Short Name
- CT Guided Bx
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.;Updated the Component to include "percutaneous" to clarify the approach and make it explicit rather than assuming its presence.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | guía para biopsia: |
| es-MX | Spanish (Mexico) | Orientación para la biopsia percutánea: |
| it-IT | Italian (Italy) | Guida per biopsia percutanea: Synonyms: Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC) |
| pt-BR | Portuguese (Brazil) | Orientação para biópsia: Synonyms: ; |
| zh-CN | Chinese (China) | 旨在经皮活组织检查的引导: Synonyms: Bx CAT 扫描; |
25069-6 Fluoroscopic guidance for biopsy of unspecified site study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Guidance for percutaneous biopsy
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- RF
Additional Names
- Short Name
- RF Guided Bx
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Method of "XR.fluor" was changed to "RF". The LOINC/RadLex Committee agreed to use a subset of the two-letter DICOM modality codes as the primary modality identifier.;Updated the Component to include "percutaneous" to clarify the approach and make it explicit rather than assuming its presence.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | guía para biopsia: |
| es-MX | Spanish (Mexico) | Orientación para la biopsia percutánea: |
| it-IT | Italian (Italy) | Guida per biopsia percutanea: Synonyms: Osservazione Punto nel tempo (episodio) Radio-fluoroscopia Radiologia |
| pt-BR | Portuguese (Brazil) | Orientação para biópsia: Synonyms: ; |
| zh-CN | Chinese (China) | 旨在经皮活组织检查的引导: Synonyms: Bx RF; |
25059-7 Ultrasound guidance for biopsy of unspecified site study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Guidance for percutaneous biopsy
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Guided Bx
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.;Updated the Component to include "percutaneous" to clarify the approach and make it explicit rather than assuming its presence.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | guía para biopsia: |
| es-MX | Spanish (Mexico) | Orientación para la biopsia percutánea: |
| it-IT | Italian (Italy) | Guida per biopsia percutanea: Synonyms: Eco Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Orientação para biópsia: Synonyms: ; |
| ru-RU | Russian (Russian Federation) | Руководство по чрескожной биопсии: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 旨在经皮活组织检查的引导: Synonyms: Bx 不明的; |
25061-3 US Unspecified body region
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Unsp region
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.64
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41853-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Multisection: Synonyms: US |
| es-AR | Spanish (Argentina) | segmento adicional: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Eco Multistrato Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Seccionais: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Мультисекция: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24731-2 Ultrasound of head study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Head
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Head
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.61
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41824-0 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Eco Multistrato Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Seccionais: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Мультисекция: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24842-7 Ultrasound of neck study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Neck
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Neck
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 4340
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41846-3 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Eco Multistrato Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Seccionais: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Мультисекция: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24558-9 Ultrasound of abdomen study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Abdomen
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Abd
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 3361
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41823-2 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Addome e Eco Multistrato Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Seccionais: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Мультисекция: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
28614-6 Ultrasound of liver study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Abdomen>Liver
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Liver
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model. Changed System from "Live" for conformance with the LOINC/RadLex unified model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 6055
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41823-2 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | proyecciones: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Addome e Eco Fegato Multistrato Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Seccionais: Synonyms: Finding; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24601-7 Ultrasound of breast study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Breast
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Brst
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 1893
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41854-7 | Region imaged: |
| LG38575-3 | US| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Multisección: |
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Eco Multistrato Osservazione Petto Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Seccionais: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Мультисекция: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
24869-0 Ultrasound of pelvis study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Multisection
- Property
- Find
- Time
- Pt
- System
- Pelvis
- Scale
- Doc
- Method
- US
Additional Names
- Short Name
- US Pelvis
Basic Attributes
- Class
- RAD
- Type
- Clinical
- First Released
- Version 1.0o
- Last Updated
- Version 2.73
- Change Reason
- The scale has been changed from "Nar" to "Doc" to fit with the CDA model.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 4207
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41848-9 | Region imaged: |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | [secciones múltiples]: |
| es-MX | Spanish (Mexico) | Multisección: |
| it-IT | Italian (Italy) | Sezioni multiple: Synonyms: Bacino Eco Multistrato Osservazione Punto nel tempo (episodio) Radiologia |
| pt-BR | Portuguese (Brazil) | Seccionais: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Мультисекция: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 多层: Synonyms: (多层（多平面、 |
28634-4 Miscellaneous studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Miscellaneous studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Common Test Rank Get Info
- 16301
- Panel Type
- Panel
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios variados: |
| it-IT | Italian (Italy) | Studi vari: Synonyms: Allegato Allegato referto clinico Complesso paziente Stabilito; |
| nl-NL | Dutch (Netherlands) | diverse onderzoeken: |
| ru-RU | Russian (Russian Federation) | Разнообразные исследования: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 杂项检查: Synonyms: 临床信息附件集; |
18742-7 Arthroscopy study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Arthroscopy study
- Property
- Find
- Time
- Pt
- System
- XXX
- Scale
- Doc
- Method
- Arthroscopy
Additional Names
- Short Name
- Arthroscopy study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Updated to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Informe de estudio: |
| es-AR | Spanish (Argentina) | informe del estudio: |
| it-IT | Italian (Italy) | Artroscopia, studio: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 关节内镜检查: Synonyms: 不明的; |
28615-3 Audiology study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Audiology study
- Property
- Find
- Time
- -
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Audiology study
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.67
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudio audiológico: |
| es-MX | Spanish (Mexico) | Estudio de audiología: |
| it-IT | Italian (Italy) | Studio di audiologia: Synonyms: Audiologia Documentazione miscellanea Miscellanea Osservazione paziente |
| nl-NL | Dutch (Netherlands) | audiologisch onderzoek: |
| pt-BR | Portuguese (Brazil) | Estudo de Audiologia: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Аудиологическое исследование: Synonyms: Документ |
| zh-CN | Chinese (China) | 听力学检查: Synonyms: 临床文档型; |
29756-4 Peritoneoscopy study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Peritoneoscopy study
- Property
- Find
- Time
- Pt
- System
- Peritoneal space
- Scale
- Doc
- Method
- Peritoneoscopy
Additional Names
- Short Name
- Peritoneoscopy study
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: updated to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe del estudio: |
| es-MX | Spanish (Mexico) | Informe de estudio: |
| it-IT | Italian (Italy) | Peritoneoscopia, studio: Synonyms: Clinico Osservazione Punto nel tempo (episodio) Studio di peritoneoscopia |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 腹腔镜检查: Synonyms: 临床文档型; |
28620-3 Urology studies (set)
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Urology studies
- Property
- Cmplx
- Time
- -
- System
- ^Patient
- Scale
- Set
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.00
- Last Updated
- Version 2.27
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | estudios urológicos: |
| it-IT | Italian (Italy) | Studi di urologia: Synonyms: Allegato Allegato referto clinico Complesso paziente Stabilito; |
| pt-BR | Portuguese (Brazil) | Estudos de Urologia: Synonyms: Complex |
| ru-RU | Russian (Russian Federation) | Урологические исследования: Synonyms: Комплекс |
| zh-CN | Chinese (China) | 泌尿外科学检查: Synonyms: 临床信息附件集; |