34133-9 Summary of Episode Note

Term Description

This LOINC term is commonly used as the Clinical Document code for both the Care Record Summary (CRS) and Continuity of Care Document (CCD), with an "episode" of care defined as the provision of care over a specified period of time that can cover one or more health care encounters. This definition was approved by the LOINC Document Ontology subcommittee in February 2021.

Part Descriptions

LP73427-4   Summary of episode note
Summarization of Episode Note contains pertinent data about the provision of care for a patient over a specified period of time. Examples include a Care Record Summary (CRS) and Continuity of Care Document (CCD). CRS includes the summary of the episode, discharge and transfer. CCD includes the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters. Such documents are commonly used in Transfer of Care scenarios. Source: HL7

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Summary of episode note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.09

Last Updated

Version 2.70 (MIN)

Change Reason

Release 2.70: DefinitionDescription: Added definition of "episode of care"; Previous Releases: Changed Component from 'Summarization of episode' per Clinical LOINC Committee decision to harmonize existing Document Ontology axes values.; 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

Member of these Groups Get Info

Language Variants Get Info

Related Names

• CCD
• Continuity of Care Document
• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Visit note

48764-5 Summary purpose CCD Document

Term Description

Specific reason for which the summarization report was generated.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Summary purpose

Property

Find

Time

Pt

System

^CCD

Scale

Doc

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• Continuity of Care Document
• DOC.MISC
• Document
• Finding
• Findings
• MISC
• Point in time
• Random

48768-6 Payment sources Document

Term Description

Contains data on the patient's payers, whether a 'third party' insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient's care.

Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient's pertinent current payment sources should be listed.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Payment sources

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Financing and insurance
• Finding
• Findings
• MISC
• Payers
• Point in time
• Random

42348-3 Advance Healthcare Directives

Term Description

Advance directives contains data defining the patient's direction of care and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. Advance directives contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Advance healthcare directives

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.16

Last Updated

Version 2.79 (NAM)

Change Reason

Release 2.79: COMPONENT: Adding the descriptor "healthcare" better reflects its intended use in healthcare contexts, updating the term to "Advance healthcare directives." This modification aims to encompass a broader range of healthcare-specific advance directives; Previous Releases: Based on Clinical LOINC Committee review at the Feb. 2016 meeting, this term represents a document containing information on a patient's advance directives and any supporting documentation, such as a living will. The term was revised to fit the current LOINC Document Ontology model.;

Order vs. Observation

Both

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Adv healthcare directives
• Advanced
• DOC.ONT
• Document
• Finding
• Findings
• Point in time
• Random

47420-5 Functional Status Assessment Note

Term Description

Functional status assessment describes the patient's status of normal functioning at the time a care record was created. Functional statuses include information regarding the patient relative to ambulatory ability, mental status or competency, activities of daily living (ADLs) (i.e. bathing, dressing, feeding, grooming), home/living situation having an effect on the health status of the patient, ability to care for self, social activity (i.e. issues with social cognition, participation with friends and acquaintances other than family members), occupation activity (i.e. activities partly or directly related to working), housework or volunteering, family and home responsibilities or activities related to home and family, communication ability (i.e. issues with speech, writing or cognition required for communication), and perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Functional status assessment note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.67 (MIN)

Change Reason

Previous Releases: Based on Clinical LOINC Committee approval on 2/17/2012, "note" was added to the Component as the Kind of Document.; 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

No IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• Functional status note
• notes
• Point in time
• Random
• Visit note

11450-4 Problem list - Reported

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Problem list

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.73 (MIN)

Common Test Rank Get Info

9889

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Nominal
• P prime
• Point in time
• Random

11323-3 General health - Reported

Term Description

Information about the current health status of the patient.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

General health

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.27 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Nominal
• P prime
• Point in time
• Random

10157-6 History of family member diseases note

Term Description

History of family member diseases is a report of health information, including medical, genetic, environmental, and lifestyle factors, pertaining to the patient and his or her genetic relatives (living or deceased). The family history information is used to determine possible or relevant health risk factors that may have a potential impact on the patient's healthcare risk profile.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

History of family member diseases note

Property

Hx

Time

Pt

System

^Family member

Scale

Doc

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; Previous Releases: Changed Property from "Find" to "Hx", removed Method of "Reported" and corrected System from Family to ^Family member to align with existing family history terms and to represent family member as a Super System per 8/2015 Clinical LOINC Committee decision;

Common Test Rank Get Info

9825

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Fam Mem
• Family member diseases Hx
• H/O
• H+P
• H+P.HX
• History
• Hx
• Hx of fam member ds note
• notes
• P prime
• Point in time
• Random
• Visit note

29762-2 Social history note

Term Description

The Social history section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Social history note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H+P
• H+P.HX
• Hx
• notes
• P prime
• Point in time
• Random
• Social Hx
• Social hx note
• Visit note

48765-2 Allergies

Term Description

Contains a list and description of any allergies or adverse reactions pertinent to current or past medical history. At a minimum this section should contain currently active and any relevant historical allergies and adverse reactions.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Allergies and adverse reactions Document

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

Change Reason

Previous Releases: Edited Component part from "Allergies, adverse reactions, alerts" to "Allergies &or adverse reactions." We removed the word "alerts" because it was potentially confusing by implying that it may contain other kinds of warnings (as a arbitrary example: public health disease outbreak notifications) when in fact it was always intended to be the typical "allergies" section.;

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• MISC
• Point in time
• Random

10160-0 History of Medication use Narrative

Term Description

History of medication use defines a patient's current medications and history of pertinent medications. This term may also include a patient's prescription and dispense history.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Change Reason

Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Narrative
• P prime
• Point in time
• Random
• Report

46264-8 History of medical device use

Term Description

History of medical device (medical equipment) use defines a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history. This term is also used to itemize any pertinent current or historical durable medical equipment (DME) used to help maintain the patient's health status. All pertinent equipment relevant to the diagnosis, care, and treatment of a patient should be included.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

History of medical device use

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.67 (MIN)

Change Reason

Previous Releases: 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

Observation

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• H/O
• Hx
• Medical device use Hx
• MISC
• Point in time
• Random

11369-6 History of Immunization note

Term Description

History of immunizations defines a patient's immunization status for the context and use case of the document type. Often included is current immunization status and possibly the entire immunization history.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Immunization note

Property

Hx

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; Previous Releases: Changed Component from "History of immunizations" to "Immunization", Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• H+P
• H+P.HX
• History
• Immunization status
• notes
• P prime
• Point in time
• Random
• Vaccination
• Vaccinations
• Vaccine
• Visit note

8716-3 Vital signs note

Term Description

The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Vital signs note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Common Test Rank Get Info

576

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H+P
• H+P.PX
• notes
• P prime
• Point in time
• Random
• Visit note

30954-2 Relevant diagnostic tests/laboratory data note

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Relevant diagnostic tests &or laboratory data note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

VACCIN

Type

Clinical

First Released

Version 2.04

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Relevant Dx tests/lab data
• Relevant dx tests/lab data note
• VACCINE
• Visit note

47519-4 History of Procedures Document

Term Description

This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically and at the time the document is generated.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

History of procedures

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

Change Reason

Previous Releases: 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.;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Finding
• Findings
• H/O
• H+P
• H+P.HX
• Hx
• P prime
• Point in time
• Procedures Hx
• Random

46240-8 History of Hospitalizations+Outpatient visits Narrative

Term Description

History of hospitalizations and History of outpatient visits (i.e. Encounters) lists and describes any healthcare encounters pertinent to the patient's current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient's condition. It may include visits, appointments, as well as non face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Hospitalizations+Outpatient visits

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

Change Reason

Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Hospitalizations+OP visits
• Narrative
• OP
• Outpt visits
• P prime
• Point in time
• Random
• Report

18776-5 Plan of Care Note

Term Description

Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Plan of care note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 1.0l

Last Updated

Version 2.67 (MIN)

Change Reason

Previous Releases: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.;

Order vs. Observation

Both

HL7^® Attachment Structure

IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Care plan
• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Treatment plan
• Visit note

48767-8 Annotation comment [Interpretation] Narrative

Term Description

This is an observation code indicating that a particular observation represents a free text annotation comment that can be appended to some other observation such as a lab result.

Observation Required in Panel

Optional

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Annotation comment

Property

Imp

Time

Pt

System

{system}

Scale

Nar

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Observation

Common Test Rank Get Info

690

Member of these Panels

Language Variants Get Info

Related Names

• cmmt
• cmnt
• Com
• Comm
• Comments
• Commt
• DOC.MISC
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• MISC
• Narrative
• Point in time
• Random
• Remarks
• Report

33999-4 Diagnosis status

Term Description

This term classifies the status of a diagnosis.

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Status

Property

Class

Time

Pt

System

{Diagnosis}

Scale

Nom

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.09

Last Updated

Version 2.72 (MIN)

Change Reason

Release 2.72: CLASS: Updated to fit the more general use.; Previous Releases: Changed answer list from "Normative" to "Example" to fit the current LOINC model.; Updated Long Common Name to better represent the meaning of the term

Example Answer List LL451-6

Member of these Panels

Language Variants Get Info

Related Names

• {Dx}
• H+P
• H+P.HX
• Nominal
• P prime
• Point in time
• Random

48766-0 Information source

Term Description

The information or data source may be a person, organization, information system, reference to some other data object, etc.

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Information source

Property

Type

Time

Pt

System

{system}

Scale

Nom

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Both

Common Test Rank Get Info

6489

Example Answer List LL3678-1

Externally Defined

Yes

Code System

CDC-PHIN

Code System OID

1.3.6.1.4.1.12009.10.1.2313

Link to External List

https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3036

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• MISC
• Nominal
• Point in time
• Random
• Source of info
• Srce
• Typ