Version 2.77

Term Description

This term is used to record the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Source: Regenstrief LOINC

Fully-Specified Name

Chief complaint+Reason for visit

Additional Names

Short Name
Chief complaint+Reason for visit

Basic Attributes

First Released
Version 2.19
Last Updated
Version 2.63
Order vs. Observation

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Queja principal + Motivo de la visita:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Plainte principale+raison de visite:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Disturbo principale+Motivo dell'incontro:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Disturbo primario Disturbo primario e Motivo dell''incontro Lamenta Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) belangrijkste klacht + reden voor bezoek:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Reclamação à chefia+Motivo da visita:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Основная жалоба+Причина визита:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Причина визита Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 主诉+就诊原因:发现:时间点:^患者:叙述型:
Synonyms: 主诉+就诊理由;主诉+就医原因;主诉+访视原因 关于就诊的理由;关于就诊(就医、访视)的原因;就诊原因;就诊理由;就医原因;访视原因;就医理由;访视理由 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 控诉;申诉;指控;不平;牢骚;委屈;意见;怨言;病痛;主诉 时刻;随机;随意;瞬间 病史与体格检查

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