Version 2.78

51898-5 Risk factors

Term Description

This is a general risk factors document for data about a patient. Originally created (but not limited in use) for HAI reporting, where the information recorded in the Risk Factors section varies according to Report type. Devices, procedures, other factors associated with risk.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Risk factors
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Risk factors Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.73
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
Both

Member of these Panels

LOINC Long Common Name
51896-9 Healthcare Associated Infection report - recommended CDA R2 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Factores de riesgo:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Fattori di rischio:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) risicofactoren:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 危险因素:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 危险因子;风险因素 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 时刻;随机;随意;瞬间 未加明确说明的角色 杂项;杂项类;杂项试验

51899-3 Details

Term Description

This is a general details document for data about a patient. Originally created (but not limited in use) for HAI reporting, where the information recorded in the details section varies according to Report type. Event or encounter details.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Details
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Details Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.73
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
Both
Common Test Rank Get Info
10144

Member of these Panels

LOINC Long Common Name
51896-9 Healthcare Associated Infection report - recommended CDA R2 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Detalles:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Dettagli:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) details:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 详情:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 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 时刻;随机;随意;瞬间 未加明确说明的角色 杂项;杂项类;杂项试验 细节;细节信息;详细信息;详细情况;具体信息;具体情况;细节情况

18769-0 Findings

Observation Required in Panel

Required

Fully-Specified Name

Component
Microbial susceptibility tests
Property
Susc
Time
Pt
System
^Patient
Scale
Set
Method

Basic Attributes

Class
ATTACH.LAB
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.73
Common Test Rank Get Info
12818

Member of these Panels

LOINC Long Common Name
51896-9 Healthcare Associated Infection report - recommended CDA R2 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Mikrobielle Empfindlichkeits-Untersuchungen:Empfindlichkeit (Mikroorganismen):Zeitpunkt:^Patient:Set:
es-AR Spanish (Argentina) antibiogramas:susceptibilidad:punto en el tiempo:^paciente:Conjunto:
fr-FR French (France) Antibiogramme:Sensibilité:Ponctuel:Patient:Statut:
it-IT Italian (Italy) Test di suscettibilità microbica:Susc:Pt:^Paziente:Determinato:
Synonyms: Allegato Allegato di laboratorio paziente Punto nel tempo (episodio) Sensibilità (microrganismi) Stabilito;Fissato
nl-NL Dutch (Netherlands) microbiële gevoeligheidstesten:gevoeligheid:moment:^patiënt:set:
ru-RU Russian (Russian Federation) Микробиологическая чувствительность тесты:Чув:ТчкВрм:^Пациент:Множество:
Synonyms: Точка во времени;Момент Чувствительность (микроорганизмов) Чувствительность к антибиотикам тесты
zh-CN Chinese (China) 微生物敏感性试验:抗生素敏感性:时间点:^患者:集合型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.实验室数据;HIPAA 信息附件.检验数据;健康保险便携与责任法案信息附件.实验室;健康保险便携与责任法案信息附件.实验室数据;健康保险便携与责任法案信息附件.检验数据;实验室数 临床信息附件集;临床信息附件集合;集;集合 信息附件;健康保险便携与责任法案信息附件;附件 化验室 化验科 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 实验室 实验室类别 微生物敏感性试验类 抗生素敏感性 抗生素敏感性(微生物);敏感性;某种抗微生物制剂对于某个分离株的影响;药物敏感性;药物敏感性(微生物) 抗生素敏感性试验 敏感性 敏感性试验 时刻;随机;随意;瞬间 检验科 药物敏感性

51900-9 Population Summary note

Term Description

This is a general summary for population level data. Originally created (but not limited in use) for HAI reporting. An example is the ICU Denominator report containing four Summary Data Observations representing patient days, central line days, urinary catheter days, and ventilator days. Summary data reporting on a population (e.g. all patients in an ICU).
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Population summary report
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Pop summary report

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.67
Change Reason
Previous Releases: Changed Component from 'Summary note' based on Clinical LOINC Committee descision to clarify the document is a summary report for a population and to harmonize with the current Document Ontology model.; 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
51896-9 Healthcare Associated Infection report - recommended CDA R2 sections
86535-2 Healthcare associated infection report - recommended CDA R3 set

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Informe resumido de población:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Popolazione, rapporto riassuntivo:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Rapporto riassuntivo della popolazione Referto Ruolo non specificato
zh-CN Chinese (China) 人群摘要报告:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 人群（群体、人口）摘要（概要、小结）报告 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 报道;汇报;调查报告;报表;报导 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色

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.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Hospitalizations+Outpatient visits
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Hospitalizations+OP visits

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.19
Last Updated
Version 2.63
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

LOINC Long Common Name
69459-6 Care record summary panel
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
51896-9 Healthcare Associated Infection report - recommended CDA R2 sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hospitalizaciones + Visitas ambulatorias:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Ospedalizzazioni+Visite ambulatoriali:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi visite paziente ambulatoriale
nl-NL Dutch (Netherlands) ziekenhuisopnames en poliklinische bezoeken:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
pt-BR Portuguese (Brazil) Histórico de hospitalizações+ Histórico de visitas ambulatoriais:Achado:Pt:^Paciente:Nar:Relatado
Synonyms: ; Outpatient visits Hx; Hospitalizations+OP visits Hx; Hospitalizations Hx; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) История госпитализаций+История амбулаторных визитов:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез госпитализаций+Анамнез амбулаторных посещений История Описательный Точка во времени;Момент
zh-CN Chinese (China) 住院治疗史+门诊就诊史:历史记录:时间点:^患者:叙述型:
Synonyms: 住院治疗历史+门诊就诊历史;住院治疗史+门诊就医史;住院治疗史+门诊患者就诊史;住院治疗史+门诊病人就诊史 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 医院收容;入院;住院期;收治入院 历史;史;病史 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 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 时刻;随机;随意;瞬间 病史与体格检查 门诊就诊类（就诊、就诊过程类、就诊过程、就医过程类、就医类、就医过程、就医）;门诊就诊类

18725-2 Microbiology studies (set)

Observation Required in Panel

Required

Fully-Specified Name

Component
Microbiology studies
Property
Cmplx
Time
-
System
^Patient
Scale
Set
Method

Basic Attributes

Class
ATTACH.LAB
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.73
Common Test Rank Get Info
17506

Member of these Panels

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
51896-9 Healthcare Associated Infection report - recommended CDA R2 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Mikrobiologische Untersuchungen:Komplex:-:^Patient:Set:
de-AT German (Austria) Mikrobiologie-Befund:komplex:-:^Patient:Set:
es-AR Spanish (Argentina) estudios de microbiología:complejo:-:^paciente:Conjunto:
fr-FR French (France) Microbiologie:Autre:-:Patient:Statut:
it-IT Italian (Italy) Studi di microbiologia:Cmplx:-:^Paziente:Determinato:
Synonyms: Allegato Allegato di laboratorio Complesso paziente Stabilito;Fissato
nl-NL Dutch (Netherlands) microbiologie studies:complex:-:^patiënt:set:
ru-RU Russian (Russian Federation) Микробиологические исследования:Кмплкс:-:^Пациент:Множество:
Synonyms: Комплекс
zh-CN Chinese (China) 微生物学检查:复合型属性:-:^患者:集合型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.实验室数据;HIPAA 信息附件.检验数据;健康保险便携与责任法案信息附件.实验室;健康保险便携与责任法案信息附件.实验室数据;健康保险便携与责任法案信息附件.检验数据;实验室数 临床信息附件集;临床信息附件集合;集;集合 信息附件;健康保险便携与责任法案信息附件;附件 化验室 化验科 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 复合属性;复杂型属性;复杂属性 实验室 实验室类别 微生物学检查类;微生物检查;微生物学（微生物）检查（检查项目） 检验科