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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.

LOINC Names Get Info

Fully-Specified Name
Chief complaint+Reason for visit:Find:Pt:^Patient:Nar:
Long Common Name
Chief complaint+Reason for visit Narrative
Short Name
Chief complaint+Reason for visit

Part Model Get Info

  • Component
    Chief complaint+Reason for visit
    LP72245-1
    • Analyte
      Chief complaint+Reason for visit
      LP72245-1
      • Component Numerator
        Chief complaint+Reason for visit
        LP72245-1
        • Component Numerator Core
          Chief complaint+Reason for visit
          LP72245-1
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Find
    LP6813-2
  • Time
    Pt
    LP6960-1
  • System
    ^Patient
    LP310005-6
    • System Core
      NULL
       
    • Super System
      Patient
      LP6985-8
  • Scale
    Nar
    LP7749-7
  • Method
    NULL
     

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.19
Last Updated
Version 2.63 (MIN)
Order vs. Observation
Observation

Member of these Panels

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

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Κύριο παράπονο+Λόγος επίσκεψης:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: - H&P.HX Nar Pt Ασθενής Εύρεση Κύριο παράπονο Κύριο παράπονο+Λόγος επίσκεψης Λόγος επίσκεψης Παράπονο
es-MXSpanish (Mexico)Queja principal + Motivo de la visita:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BEFrench (Belgium)Plainte principale+raison de visite:Observation:Temps ponctuel:^Patient:Narratif:
it-ITItalian (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-NLDutch (Netherlands)belangrijkste klacht + reden voor bezoek:bevinding:moment:^patiënt:tekstueel:
pt-BRPortuguese (Brazil)Reclamação à chefia+Motivo da visita:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
ru-RURussian (Russian Federation)Основная жалоба+Причина визита:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Причина визита Проблема;Заболевание Точка во времени;Момент
zh-CNChinese (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

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=46239-0