Version 2.78

11485-0 Anesthesia records

Type of Entry

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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-AR Spanish (Argentina) registros de anestesia:hallazgo:-:^paciente:Múltiple:
es-MX Spanish (Mexico) Registros de anestesia:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Anestesia, registri:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) anesthesiedossier:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Анестезия записи:Находка:-:^Пациент:Док:
Synonyms: Документ Записи об анестезии
zh-CN Chinese (China) 麻醉记录:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验 麻醉档案;麻醉病历

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-AR Spanish (Argentina) registros de quimioterapia:hallazgo:-:^paciente:Múltiple:
es-MX Spanish (Mexico) Registros de quimioterapia:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Chemioterapia, registri:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) chemotherapiedossier:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Химиотерапия записи:Находка:-:^Пациент:Док:
Synonyms: Документ Записи по химиотерапии
zh-CN Chinese (China) 化学疗法记录:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 化学治疗;化疗 化学治疗记录;化疗记录;化学疗法病历;化学疗法档案 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验

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:hallazgo:-:^paciente:Múltiple:
es-MX Spanish (Mexico) Registros de cuidados críticos:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Registri di assistenza critica:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) IC-dossier:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Критическое состояние помощь записи:Находка:-:^Пациент:Док:
Synonyms: Документ Записи о помощи - интенсивной терапии и реанимации
zh-CN Chinese (China) 危重病监护记录:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 危重病监护档案;危重病监护病历 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验

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:Ergebnis:-:^Patient:Dokument:
es-AR Spanish (Argentina) registros de diálisis:hallazgo:-:^paciente:Múltiple:
es-MX Spanish (Mexico) Registros de diálisis:Tipo:-:^ Paciente:Documento:
fr-FR French (France) Dossier de dialyse:Recherche:-:Patient:Document:
it-IT Italian (Italy) Registri dialisi:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) dialysedossier:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Диализ записи:Находка:-:^Пациент:Док:
Synonyms: Документ
zh-CN Chinese (China) 透析记录:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验 渗析 渗析;肾脏透析;肾透析;血液透析;血透 血透 透析 透析（渗析、肾脏透析、肾透析、血液透析、血透）（记录、档案、病历）;透析档案;透析病历

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-AR Spanish (Argentina) registros de parto y trabajo de parto:hallazgo:-:^paciente:Múltiple:
es-MX Spanish (Mexico) Registros de trabajo de parto y parto:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Travaglio e parto, registri:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) dossier zwangerschap en bevalling:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Роды и родоразрешение записи:Находка:-:^Пациент:Док:
Synonyms: Документ Записи о роды и родоразрешение
zh-CN Chinese (China) 临产和分娩记录:发现:-:^患者:文档型:
Synonyms: 临产（阵痛）和分娩记录（病历、档案）;阵痛和分娩记录;分娩记录;临产和分娩病历;临产和分娩档案 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验

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-AR Spanish (Argentina) registros médicos:hallazgo:-:^paciente:Múltiple:
es-MX Spanish (Mexico) Registros médicos:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Cartelle cliniche:Osservazione:-:^Paziente:Doc:
Synonyms: Cartelle mediche Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) medisch dossier:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Медицинские записи:Находка:-:^Пациент:Док:
Synonyms: Документ
zh-CN Chinese (China) 病历类:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验 病历;病案;医疗记录;医疗档案

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-MX Spanish (Mexico) Registros de cuidados intensivos neonatales:Tipo:-:^ Paciente:Documento:
es-AR Spanish (Argentina) registros de atención neonatal intensiva:hallazgo:-:^paciente:Múltiple:
it-IT Italian (Italy) Registri di terapia intensiva neonatale:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) neonatale intensieve zorg dossier:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Неонатальная интенсивная помощь записи:Находка:-:^Пациент:Док:
Synonyms: Документ
zh-CN Chinese (China) 新生儿重症监护记录:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 新生儿重症监护档案;新生儿重症监护病历 杂项;杂项类;杂项试验

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-AR Spanish (Argentina) registros de sala de recién nacidos:hallazgo:-:^paciente:Múltiple:
es-MX Spanish (Mexico) Registros de guardería:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Registri nido ospedaliero:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) verpleegkundig dossier:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Детская комната записи:Находка:-:^Пациент:Док:
Synonyms: Документ
zh-CN Chinese (China) 婴儿室记录:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 婴儿室（托儿所、保育室、幼儿园、儿童室、临时托儿所）病历（档案、记录） 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验

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-MX Spanish (Mexico) Registros perioperatorios:Tipo:-:^ Paciente:Documento:
es-AR Spanish (Argentina) registros perioperatorios:hallazgo:-:^paciente:Múltiple:
it-IT Italian (Italy) Documenti perioperatori:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) peri-operatief dossier:bevinding:-:^patiënt:document:
ru-RU Russian (Russian Federation) Периоперационные записи:Находка:-:^Пациент:Док:
Synonyms: Документ
zh-CN Chinese (China) 围手术期记录:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 围手术期病历;围手术期档案 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验

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:Ergebnis:-:^Patient:Dokument:
Synonyms: Auftrag
es-MX Spanish (Mexico) Órdenes de proveedores:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Provider, ordini:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Ordini del care provider Osservazione paziente
pt-BR Portuguese (Brazil) Encomendas ao fornecedor:Achado:-:^Paciente:Doc:
Synonyms: Finding; Findings
ru-RU Russian (Russian Federation) Провайдер заказы:Находка:-:^Пациент:Док:
Synonyms: Документ
zh-CN Chinese (China) 服务提供者医嘱:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 服务提供者（提供方、提供者、服务人员、服务提供方、服务方、服务机构、服务者）医嘱（医令、指示、嘱托、嘱咐） 杂项;杂项类;杂项试验

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-AR Spanish (Argentina) fichas de temperatura:hallazgo:-:^paciente:Múltiple:
es-MX Spanish (Mexico) Gráficos de temperatura:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Grafici della temperatura:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente
nl-NL Dutch (Netherlands) temperatuuroverzicht:bevinding:-:^patiënt:document:
pt-BR Portuguese (Brazil) Gráficos de temperatura:Achado:-:^Paciente:Doc:
Synonyms: ; Temp charts; Finding; Findings
ru-RU Russian (Russian Federation) Температурные карты:Находка:-:^Пациент:Док:
Synonyms: Документ Температурные листы
zh-CN Chinese (China) 体温单:发现:-:^患者:文档型:
Synonyms: Temperature charts;温度图;温度图表;体温图;体温图表 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 体温 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 杂项;杂项类;杂项试验