Version 2.77

10186-5 Identifying information Narrative Observed

Fully-Specified Name

Component
Identifying information
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Observed

Additional Names

Short Name
Identifying information Observ

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Información identificativa:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
es-AR Spanish (Argentina) información identificatoria:hallazgo:punto en el tiempo:^paciente:Narrativo:observado
fr-BE French (Belgium) Informations identification:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Informazione identificante:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Идентифицирующая информация:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 标识信息:发现:时间点:^患者:叙述型:观察法
Synonyms: 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 时刻;随机;随意;瞬间 病史与体格检查 观测法 身份信息;身份标识信息;身份证明信息;身份证件信息

11288-8 Arrival time documented

Fully-Specified Name

Component
Arrival time documented
Property
ClockTime
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Arrival time documented Clock time

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.48

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hora de llegada documentada:Hora del reloj:Punto temporal:^ Paciente:Cuantitativo:
es-AR Spanish (Argentina) hora de llegada documentada:tiempo:punto en el tiempo:^paciente:cuantitativo:
it-IT Italian (Italy) Ora di arrivo documentata:ClockTime:Pt:^Paziente:Qn:
Synonyms: Emergenza (DEEDS - Data Elements for Emergency Dep Ora paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Tempo de visita documentada:Tempo:Pt:^Paciente:Qn:
Synonyms: Point in time; Random; Quantitative; QNT; Quant; Quan; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Прибытие время документировано:ClockTime:ТчкВрм:^Пациент:Колич:
Synonyms: Время, измеренное при помощи хронометра (часов) Количественный Точка во времени;Момент
zh-CN Chinese (China) 文档记录的到达时间:时钟时间:时间点:^患者:定量型:
Synonyms: ED 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 已记载的到达时间;已记录的到达时间 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 时刻;随机;随意;瞬间 时间(如秒);时间(如秒数) 钟表时间

Example Units

Unit Source
{clock_time} Example UCUM Units

11459-5 Transport mode EMS system

Fully-Specified Name

Component
Transport mode
Property
Type
Time
Pt
System
EMS system
Scale
Nom
Method

Additional Names

Short Name
Transport mode EMS Sys

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63

Normative Answer List LL483-9

Answer Code Score Answer ID
Ground ambulance 10 LA9315-8
Helicopter ambulance 20 LA9316-6
Fixed-wing air ambulance 30 LA9317-4
Ambulance, not otherwise specified 40 LA9318-2
Walk-in following transport via private transportation 50 LA9319-0
Walk-in following transport via public transportation 60 LA9320-8
Walk-in following nonambulance, law enforcement transport 70 LA9321-6
Walk-in, not otherwise specified 80 LA9322-4
Other mode of transport 88 LA9323-2
Unknown mode of transport 99 LA9324-0

Member of these Panels

LOINC Long Common Name
81898-9 Composite triage and nursing note - recommended IHE set
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) TRANSPORT MODE:tipo:punto en el tiempo:sistema de servicio médico de urgencias:Nominal:
es-MX Spanish (Mexico) Modo de transporte:Tipo:Punto temporal:Sistema EMS:Nominal:
it-IT Italian (Italy) Trasporto, modo:Tipo:Pt:Servizi Medici di Emergenza, sistema:Nom:
Synonyms: Emergenza (DEEDS - Data Elements for Emergency Dep Modalità di trasporto Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Modo de transporte:Tipo:Pt:Sistema EMS:Nom:
Synonyms: Typ; Point in time; Random; EMS Sys; Nominal; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Транспортировка режим:Тип:ТчкВрм:Скорая медицинская помощь система:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 运输方式:类型:时间点:急救医疗服务系统:名义型:
Synonyms: ED EMS 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 型 急救医疗服务(Emergency Medical Service,Emergency Medical Services,EMS) 急救医疗服务(EMS 服务、急诊医学服务、急诊服务、急救服务、急症室服务、EMS、急诊医学、急诊、急救、急症室)系统;急救医疗服务(EMS 服务、急诊医学服务、急诊服务、急救服务、急症室服务、EMS、急诊医学、急诊、急救、急症室)系统 急诊医疗服务 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 时刻;随机;随意;瞬间 紧救医疗服务 运输(输送、运送)方式(模式)

11319-1 Ambulance transport unit [Identifier] EMS system

Fully-Specified Name

Component
Ambulance transport unit
Property
ID
Time
Pt
System
EMS system
Scale
Nom
Method

Additional Names

Short Name
Ambulance transport unit EMS Sys

Basic Attributes

Class
ADMIN.ID
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.66

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Unidad de transporte de ambulancia:ID:Punto temporal:Sistema EMS:Nominal:
es-AR Spanish (Argentina) unidad de transporte del servicio de emergencias médicas:intradérmico:punto en el tiempo:sistema de servicio médico de urgencias:Nominal:
it-IT Italian (Italy) Unità di trasporto in ambulanza:ID:Pt:Servizi Medici di Emergenza, sistema:Nom:
Synonyms: Amministrativo Identificatore Numero di identificazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Unidade de Ambulância:ID:Pt:Sistema EMS:Nom:
Synonyms: Identifier; Ident; Point in time; Random; EMS Sys; Nominal; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Скорая медицинская помощь транспорт единица:ID:ТчкВрм:Скорая медицинская помощь система:Ном:
Synonyms: Идентификатор Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 救护车运输单位:标识符:时间点:急救医疗服务系统:名义型:
Synonyms: EMS 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 急救医疗服务(Emergency Medical Service,Emergency Medical Services,EMS) 急救医疗服务(EMS 服务、急诊医学服务、急诊服务、急救服务、急症室服务、EMS、急诊医学、急诊、急救、急症室)系统;急救医疗服务(EMS 服务、急诊医学服务、急诊服务、急救服务、急症室服务、EMS、急诊医学、急诊、急救、急症室)系统 急诊医疗服务 救护车运送单位 时刻;随机;随意;瞬间 标志 标志符 标识 标识;身份标识符;身份标识 标识符 标识符(Identifier,ID) 皮下 皮下的 皮内 皮内(Intradermal,ID) 皮内的 皮层内 皮层内的 真皮下 真皮下的 真皮内的 紧救医疗服务 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).标识号(识别号、标识符、身份标识符、识别数、识别号码、标识号码、标识编号、身份编号、身份标识号、身份证号码、证件号码) 识别 识别符

11318-3 Ambulance transport agency EMS system

Fully-Specified Name

Component
Ambulance transport agency
Property
ID
Time
Pt
System
EMS system
Scale
Nom
Method

Additional Names

Short Name
Ambulance transport agency EMS Sys

Basic Attributes

Class
ADMIN.ID
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.66

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Agencia de transporte de ambulancias:ID:Punto temporal:Sistema EMS:Nominal:
es-AR Spanish (Argentina) oficina de transporte del servicio de emergencias médicas:intradérmico:punto en el tiempo:sistema de servicio médico de urgencias:Nominal:
it-IT Italian (Italy) Agenzia di trasporto in ambulanza:ID:Pt:Servizi Medici di Emergenza, sistema:Nom:
Synonyms: Amministrativo Identificatore Numero di identificazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Agência de Ambulância:ID:Pt:Sistema EMS:Nom:
Synonyms: Identifier; Ident; Point in time; Random; EMS Sys; Nominal; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Скорая медицинская помощь транспорт ведомство:ID:ТчкВрм:Скорая медицинская помощь система:Ном:
Synonyms: Идентификатор Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 救护车运输机构:标识符:时间点:急救医疗服务系统:名义型:
Synonyms: EMS 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 急救医疗服务(Emergency Medical Service,Emergency Medical Services,EMS) 急救医疗服务(EMS 服务、急诊医学服务、急诊服务、急救服务、急症室服务、EMS、急诊医学、急诊、急救、急症室)系统;急救医疗服务(EMS 服务、急诊医学服务、急诊服务、急救服务、急症室服务、EMS、急诊医学、急诊、急救、急症室)系统 急诊医疗服务 救护车运送机构 时刻;随机;随意;瞬间 标志 标志符 标识 标识;身份标识符;身份标识 标识符 标识符(Identifier,ID) 皮下 皮下的 皮内 皮内(Intradermal,ID) 皮内的 皮层内 皮层内的 真皮下 真皮下的 真皮内的 紧救医疗服务 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).标识号(识别号、标识符、身份标识符、识别数、识别号码、标识号码、标识编号、身份编号、身份标识号、身份证号码、证件号码) 识别 识别符

11293-8 Type of Referral source

Fully-Specified Name

Component
Class
Property
Type
Time
Pt
System
Referral source
Scale
Nom
Method

Additional Names

Short Name
Referral Source Class

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.27

Normative Answer List LL484-7

Answer Code Score Answer ID
Self-referral 10 LA9325-7
EMS transport decision 20 LA9326-5
Practitioner or health care facility referral 30 LA9327-3
Internal facility referral or transfer 40 LA9328-1
Law enforcement referral 50 LA9329-9
Acute care hospital transfer 60 LA9330-7
Other health care facility transfer 70 LA9331-5
Other 88 LA46-8

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Clase:Tipo:Punto temporal:Fuente de referencia:Nominal:
es-AR Spanish (Argentina) clase:tipo:punto en el tiempo:fuente de duración:Nominal:
it-IT Italian (Italy) Classe:Tipo:Pt:Fonte del rinvio:Nom:
Synonyms: Emergenza (DEEDS - Data Elements for Emergency Dep Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Classe:Tipo:Pt:Fonte de referência:Nom:
Synonyms: Typ; Point in time; Random; Nominal; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Класс:Тип:ТчкВрм:Направление источник:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 分类:类型:时间点:转诊来源:名义型:
Synonyms: ED 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 型 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 族;种类;等;类;类别;级;纲;组 时刻;随机;随意;瞬间 源 转诊(转诊介绍、转介、送交、转送、转诊介绍信)来源;转诊介绍来源;转诊介绍信来源

46239-0 Chief complaint+Reason for visit Narrative

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

Component
Chief complaint+Reason for visit
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Chief complaint+Reason for visit

Basic Attributes

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

11371-2 Initial visit for chief complaint

Fully-Specified Name

Component
Initial visit for chief complaint
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Initial visit for chief complaint

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.29

Normative Answer List LL485-4

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
No (chief complaint attributable to illness or injury, but this is not the initial encounter) 2 LA9334-9
Other (chief complaint not attributable to illness or injury) 8 LA9335-6

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Visita inicial para la queja principal:Tipo:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) primera visita por el motivo de consulta:tipo:punto en el tiempo:^paciente:Nominal:
it-IT Italian (Italy) Visita iniziale per disturbo principale:Tipo:Pt:^Paziente:Nom:
Synonyms: Anamnesi Disturbo primario Lamenta paziente Punto nel tempo (episodio) Visita iniziale per disturbo primario
pt-BR Portuguese (Brazil) Visita inicial para reclamação à chefia:Tipo:Pt:^Paciente:Nom:
Synonyms: Typ; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Первоначальный визит по основная жалоба:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 针对主诉的初始就诊:类型:时间点:^患者:名义型:
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 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 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 针对主诉的初始(初期、最初、初次)就诊(就医)

11283-9 Acuity assessment [Function] at First encounter

Fully-Specified Name

Component
Acuity assessment
Property
Fcn
Time
Enctr^frst
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Acuity assess 1st enctr

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Change Reason
Previous Releases: Changed answer list from "Normative" to "Preferred" to fit the current LOINC model.;
Common Test Rank Get Info
241

Preferred Answer List LL486-2

Answer Code Score Answer ID
Requires immediate evaluation or treatment 10 LA9336-4
Requires prompt evaluation or treatment 20 LA9337-2
Time to evaluation or treatment not critical 30 LA9338-0
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 99 LA4489-6

Member of these Panels

LOINC Long Common Name
81898-9 Composite triage and nursing note - recommended IHE set
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Evaluación de la agudeza:Fcn:Encuentro^PrimerValor:^ Paciente:Nominal:
es-AR Spanish (Argentina) evaluación de la agudeza:función:duración del primer encuentro:^paciente:ordinal o cuantitativo:
it-IT Italian (Italy) Acutezza, valutazione:Fcn:Enctr^primo:^Paziente:Nom:
Synonyms: Clinico Funzione Incontro;Appuntamento paziente Valutazione di acutezza
nl-NL Dutch (Netherlands) vaststelling acute karakter:functie:ontmoeting^eerste:^patiënt:nominaal:
pt-BR Portuguese (Brazil) Avaliação de acuidade:Fcn:Enctr^frst:^Paciente:Nom:
Synonyms: ; Acuity assess; Function; Encounter; 1st; Nominal
ru-RU Russian (Russian Federation) Острота оценка:Функц:Встрч^первый:^Пациент:Ном:
Synonyms: Встреча Номинальный;Именной Функция
zh-CN Chinese (China) 病情危急程度评估:功能:就医过程持续时间^第一:^患者:名义型:
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 就医;就医过程 病情(疾病)危急(剧烈、严重、危及、紧急)程度评估(评价、估计、估价、评论、估定、估算) 第一个;第一次;首个;首次 评价;估计;估价;评论;估定;估算

11454-6 Responsiveness assessment at First encounter

Fully-Specified Name

Component
Responsiveness assessment
Property
Fcn
Time
Enctr^frst
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Responsiveness assessment 1st enctr

Basic Attributes

Class
FUNCTION
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.27

Normative Answer List LL487-0

Answer Code Score Answer ID
Alert 1 LA9340-6
Verbal response 2 LA9341-4
Painful response 3 LA9342-2
Unresponsive Copyright http://snomed.info/sct ID:422768004 unresponsive (finding) 4 LA9343-0

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) evaluación de la respuesta:función:duración del primer encuentro:^paciente:ordinal:
es-MX Spanish (Mexico) Evaluación de la capacidad de respuesta:Fcn:Encuentro^PrimerValor:^ Paciente:Ordinal:
it-IT Italian (Italy) Reattività, valutazione:Fcn:Enctr^primo:^Paziente:Ord:
Synonyms: Funzione Incontro;Appuntamento paziente Status funzionale (es., Glasgow) Valutazione della reattività
pt-BR Portuguese (Brazil) Avaliação de responsabilidade:Fcn:Enctr^frst:^Paciente:Ord:
Synonyms: Encounter; 1st; Ql; Ordinal; QL; Qualitative; Qual; Screen; Funct; Func
ru-RU Russian (Russian Federation) Ответная реакция оценка:Функц:Встрч^первый:^Пациент:Пор:
Synonyms: Встреча Порядковый Функция
zh-CN Chinese (China) 反应性评估:功能:就医过程持续时间^第一:^患者:序数型:
Synonyms: FCN 体格功能;体格检查功能;功能;躯体功能;身体功能 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 响应性评估(评价、估计、估价、评论、估定、估算) 就医;就医过程 第一个;第一次;首个;首次 评价;估计;估价;评论;估定;估算

11324-1 Glasgow coma score eye opening at First encounter

Fully-Specified Name

Component
Glasgow coma score.eye opening
Property
Fcn
Time
Enctr^frst
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
GCS eye 1st enctr

Basic Attributes

Class
FUNCTION
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.27

Normative Answer List LL488-8

Answer Code Score Answer ID
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) 1 1 LA137-2
Opens eyes in response to painful stimulation 2 2 LA9345-5
Opens eyes in response to verbal stimulation 3 3 LA9346-3
Opens eyes spontaneously 4 4 LA9347-1
Not assessed 8 LA9348-9

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Puntaje de coma de Glasgow. Apertura de ojos:Fcn:Encuentro^PrimerValor:^ Paciente:Ordinal:
es-AR Spanish (Argentina) puntaje de Glasgow.apertura ocular:función:duración del primer encuentro:^paciente:cuantitativo:
it-IT Italian (Italy) Punteggio del coma di Glasgow.apertura occhi:Fcn:Enctr^primo:^Paziente:Ord:
Synonyms: Apertura occhi in punteggio del coma di Glasgow Funzione Incontro;Appuntamento Occhio in punteggio del coma di Glasgow paziente Status funzionale (es., Glasgow)
ru-RU Russian (Russian Federation) Glasgow кома шкала.глаза открывание:Функц:Встрч^первый:^Пациент:Пор:
Synonyms: Встреча Итог Порядковый Функция
zh-CN Chinese (China) 格拉斯哥昏迷分值.睁眼:功能:就医过程持续时间^第一:^患者:序数型:
Synonyms: FCN GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.眼睛;格拉斯哥昏迷得分.眼睛;格拉斯哥昏迷评分.眼睛 GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.睁眼;格拉斯哥昏迷得分.睁眼;格拉斯哥昏迷评分.睁眼 体格功能;体格检查功能;功能;躯体功能;身体功能 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 分值;分数;得分 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 就医;就医过程 目;眼;眼部 第一个;第一次;首个;首次

11326-6 Glasgow coma score verbal at First encounter

Fully-Specified Name

Component
Glasgow coma score.verbal
Property
Fcn
Time
Enctr^frst
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
GCS verbal 1st enctr

Basic Attributes

Class
FUNCTION
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.27

Normative Answer List LL489-6

Answer Code Score Answer ID
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) 1 LA137-2
Nonspecific sounds 2 1 LA9350-5
non-infant: Inappropriate words; non-verbal infant: Cries to pain, screams to pain 3 2 LA9351-3
non-infant: Confused conversation or speech; non-verbal infant: Irritable cries 4 3 LA9352-1
non-infant: Oriented and appropriate speech; non-verbal infant: Coos and babbles 5 4 LA9353-9

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Puntuación de coma de Glasgow verbal:Fcn:Encuentro^PrimerValor:^ Paciente:Ordinal:
es-AR Spanish (Argentina) puntaje de Glasgow.respuesta verbal:función:duración del primer encuentro:^paciente:cuantitativo:
it-IT Italian (Italy) Punteggio del coma di Glasgow.verbale:Fcn:Enctr^primo:^Paziente:Ord:
Synonyms: Funzione Incontro;Appuntamento paziente Punteggio verbale del coma di Glasgow Status funzionale (es., Glasgow)
ru-RU Russian (Russian Federation) Glasgow кома шкала.вербалика:Функц:Встрч^первый:^Пациент:Пор:
Synonyms: Встреча Итог Порядковый Функция
zh-CN Chinese (China) 格拉斯哥昏迷分值.言语:功能:就医过程持续时间^第一:^患者:序数型:
Synonyms: FCN GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.言语;格拉斯哥昏迷得分.言语;格拉斯哥昏迷评分.言语;格拉斯哥昏迷分值.语言 体格功能;体格检查功能;功能;躯体功能;身体功能 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 分值;分数;得分 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 就医;就医过程 第一个;第一次;首个;首次

11325-8 Glasgow coma score motor at First encounter

Fully-Specified Name

Component
Glasgow coma score.motor
Property
Fcn
Time
Enctr^frst
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
GCS motor 1st enctr

Basic Attributes

Class
FUNCTION
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.27

Normative Answer List LL490-4

Answer Code Score Answer ID
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) 1 LA137-2
Adult: Extensor posturing in response to painful stimulation; infant or child: Abnormal extension (decerebrate) 2 1 LA9355-4
Adult: Flexor posturing in response to painful stimulation; infant or child: Abnormal flexion (decorticate) 3 2 LA9356-2
Adult: General withdrawal in response to painful stimulation; infant or child: Withdraws to pain 4 3 LA9357-0
Adult: Localization of painful stimulation; infant or child: Withdraws to touch 5 4 LA9358-8
Adult: Obeys commands with appropriate motor response; infant or child: Normal spontaneous movement 6 5 LA9359-6

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Puntuación de coma de Glasgow motor:Fcn:Encuentro^PrimerValor:^ Paciente:Ordinal:
es-AR Spanish (Argentina) puntaje de Glasgow.respuesta motriz:función:duración del primer encuentro:^paciente:cuantitativo:
it-IT Italian (Italy) Punteggio del coma di Glasgow.motorio:Fcn:Enctr^primo:^Paziente:Ord:
Synonyms: Funzione Incontro;Appuntamento paziente Punteggio motorio del coma di Glasgow Status funzionale (es., Glasgow)
ru-RU Russian (Russian Federation) Glasgow кома шкала.моторика:Функц:Встрч^первый:^Пациент:Пор:
Synonyms: Встреча Итог Порядковый Функция
zh-CN Chinese (China) 格拉斯哥昏迷分值.运动:功能:就医过程持续时间^第一:^患者:序数型:
Synonyms: FCN GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.运动;格拉斯哥昏迷得分.运动;格拉斯哥昏迷评分.运动 体格功能;体格检查功能;功能;躯体功能;身体功能 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 分值;分数;得分 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 就医;就医过程 第一个;第一次;首个;首次

11378-7 Systolic blood pressure at First encounter

Fully-Specified Name

Component
Intravascular systolic
Property
Pres
Time
Enctr^frst
System
Arterial system
Scale
Qn
Method

Additional Names

Short Name
BP sys 1st enctr

Basic Attributes

Class
BP.MOLEC
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Common Test Rank Get Info
2379

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Sistólica intravascular:Pres:Encuentro^PrimerValor:Sistema arterial:Cuantitativo:
es-AR Spanish (Argentina) sistólico intravascular:presión:duración del primer encuentro:sistema arterial:cuantitativo:
fr-CA French (Canada) Intravasculaire systolique:Pression:Rencontre^première:Système artériel:Quantitatif:
it-IT Italian (Italy) Sistolica intravascolare:Pres:Enctr^primo:Sistema arterioso:Qn:
Synonyms: Incontro;Appuntamento Pressione Pressione arteriosa - molecolare
nl-NL Dutch (Netherlands) intravasculaire systolische bloeddruk:druk:ontmoeting^eerste:arterieel vaatstelsel:kwantitatief:
pt-BR Portuguese (Brazil) Intravascular sistólica:Pres:Enctr^frst:Sistema arterial:Qn:
Synonyms: ; BP sys; Pressure; Encounter; 1st; Art sys; Quantitative; QNT; Quant; Quan; IV; Intravenous; BLOOD PRESSURE MEASUREMENTS.MOLEC; BLOOD PRESSURE MEASUREMENTS.MOLEC; BP systolic; Blood pressure systolic; Sys BP; SBP
ru-RU Russian (Russian Federation) Интраваскулярный систолический:Давл:Встрч^первый:Артериальная система:Колич:
Synonyms: Встреча Давление Количественный
zh-CN Chinese (China) 血管内心脏收缩期:压力或压强:就医过程持续时间^第一:动脉系统:定量型:
Synonyms: 压力;压强 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 就医;就医过程 特殊血压;血压.分子型;血压指标.分子型 第一个;第一次;首个;首次 血管内收缩期;血管内心缩期 血管内的

Example Units

Unit Source
mm[Hg] Example UCUM Units

11377-9 Diastolic blood pressure at First encounter

Fully-Specified Name

Component
Intravascular diastolic
Property
Pres
Time
Enctr^frst
System
Arterial system
Scale
Qn
Method

Additional Names

Short Name
BP dias 1st enctr

Basic Attributes

Class
BP.MOLEC
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Common Test Rank Get Info
2378

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Diastólica intravascular:Pres:Encuentro^PrimerValor:Sistema arterial:Cuantitativo:
es-AR Spanish (Argentina) diastólico intravascular:presión:duración del primer encuentro:sistema arterial:cuantitativo:
fr-CA French (Canada) Intravasculaire diastolique:Pression:Rencontre^première:Système artériel:Quantitatif:
it-IT Italian (Italy) Diastolica intravascolare:Pres:Enctr^primo:Sistema arterioso:Qn:
Synonyms: Incontro;Appuntamento Pressione Pressione arteriosa - molecolare
nl-NL Dutch (Netherlands) intravasculaire diastolische bloeddruk:druk:ontmoeting^eerste:arterieel vaatstelsel:kwantitatief:
pt-BR Portuguese (Brazil) Intravascular diastólica:Pres:Enctr^frst:Sistema arterial:Qn:
Synonyms: ; BP dias; Dias; Diast; Pressure; Encounter; 1st; Art sys; Quantitative; QNT; Quant; Quan; IV; Intravenous; Diastoli; BLOOD PRESSURE MEASUREMENTS.MOLEC; BLOOD PRESSURE MEASUREMENTS.MOLEC; Blood pressure diastolic; BP diastolic; Dias BP; DBP
ru-RU Russian (Russian Federation) Интраваскулярный диастолический:Давл:Встрч^первый:Артериальная система:Колич:
Synonyms: Внутрисосудистый диастолический Встреча Давление Количественный
zh-CN Chinese (China) 血管内心脏舒张期:压力或压强:就医过程持续时间^第一:动脉系统:定量型:
Synonyms: 压力;压强 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 就医;就医过程 特殊血压;血压.分子型;血压指标.分子型 第一个;第一次;首个;首次 血管内心舒期;血管内舒张期 血管内的

Example Units

Unit Source
mm[Hg] Example UCUM Units

11328-2 Heart rate at First encounter

Fully-Specified Name

Component
Heart rate
Property
NRat
Time
Enctr^frst
System
Arterial system
Scale
Qn
Method

Additional Names

Short Name
Heart rate 1st enctr
Consumer Name Alpha Get Info
First Heart rate in Encounter

Basic Attributes

Class
HRTRATE.ATOM
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.42

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Ritmo cardiaco:NRat:Encuentro^PrimerValor:Sistema arterial:Cuantitativo:
es-AR Spanish (Argentina) latido cardíaco:índice numérico:duración del primer encuentro:sistema arterial:cuantitativo:
it-IT Italian (Italy) Frequenza cardiaca:NRat:Enctr^primo:Sistema arterioso:Qn:
Synonyms: Frequenza cardiaca - atomica Incontro;Appuntamento Indice numerico
nl-NL Dutch (Netherlands) hartslagfrequentie:aantal/tijd:ontmoeting^eerste:arterieel vaatstelsel:kwantitatief:
pt-BR Portuguese (Brazil) Frequência cardíaca:NRat:Enctr^frst:Sistema arterial:Qn:
Synonyms: ; nRate; Number rate; Count/time; Encounter; 1st; Art sys; Quantitative; QNT; Quant; Quan; Pulse; Heart beat; HEART RATE.ATOM; HEART RATE.ATOM
ru-RU Russian (Russian Federation) Частота сердечных сокращений:КолСкор:Встрч^первый:Артериальная система:Колич:
Synonyms: Встреча Количественный Количество скорость
zh-CN Chinese (China) 心率:计数型速率:就医过程持续时间^第一:动脉系统:定量型:
Synonyms: 一般心率 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 就医;就医过程 心搏率;心跳速率 第一个;第一次;首个;首次 速度

Example Units

Unit Source
{beats}/min Example UCUM Units

11291-2 Respiratory rate at First encounter

Fully-Specified Name

Component
Breaths
Property
NRat
Time
Enctr^frst
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
Resp rate 1st enctr

Basic Attributes

Class
RESP.TIMED.MOLEC
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.44

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Respiraciones:NRat:Encuentro^PrimerValor:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) respiraciones:índice numérico:duración del primer encuentro:^paciente:cuantitativo:
it-IT Italian (Italy) Respiri:NRat:Enctr^primo:Apparato respiratorio:Qn:
Synonyms: Incontro;Appuntamento Indice numerico Respiratorio - cronometrato - molecolare
pt-BR Portuguese (Brazil) Respirações:NRat:Enctr^frst:^Paciente:Qn:
Synonyms: ; nRate; Number rate; Count/time; Encounter; 1st; Quantitative; QNT; Quant; Quan; RESPIRATORY; Respiratory rate
ru-RU Russian (Russian Federation) Дыхание:КолСкор:Встрч^первый:Дыхательная система:Колич:
Synonyms: Встреча Количественный Количество скорость
zh-CN Chinese (China) 呼吸:计数型速率:就医过程持续时间^第一:呼吸系统:定量型:
Synonyms: 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸 呼吸类 呼吸类指标 呼吸类指标.定时型.分子型;定时型特殊呼吸类指标;定时型特殊呼吸系统类指标 呼吸系统 呼吸系统类 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 就医;就医过程 第一个;第一次;首个;首次

Example Units

Unit Source
{breaths}/min Example UCUM Units

11289-6 Body temperature at First encounter

Fully-Specified Name

Component
Body temperature
Property
Temp
Time
Enctr^frst
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Bdy temp 1st enctr

Basic Attributes

Class
BDYTMP.ATOM
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Common Test Rank Get Info
156

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Temperatura corporal:Temperatura:Encuentro^PrimerValor:^ Paciente:Cuantitativo:
es-AR Spanish (Argentina) temperatura corporal:temperatura:duración del primer encuentro:^paciente:cuantitativo:
fr-CA French (Canada) Température corporelle:Température:Rencontre^première:^Patient:Quantitatif:
fr-FR French (France) Température corporelle:Température:Consultation 1:Patient:Numérique:
it-IT Italian (Italy) Temperatura corporea:Temp:Enctr^primo:^Paziente:Qn:
Synonyms: Incontro;Appuntamento paziente Temperatura Temperatura del corpo - atomica
nl-NL Dutch (Netherlands) lichaamstemperatuur:temperatuur:ontmoeting^eerste:^patiënt:kwantitatief:
pt-BR Portuguese (Brazil) Temperatura corpórea:Temp:Enctr^frst:^Paciente:Qn:
Synonyms: ; Bdy temp; Encounter; 1st; Quantitative; QNT; Quant; Quan; bod; Bodies; BODY TEMPERATURE.ATOM; BODY TEMPERATURE.ATOM
ru-RU Russian (Russian Federation) Температура тела:Темп:Встрч^первый:^Пациент:Колич:
Synonyms: Встреча Количественный Температура
zh-CN Chinese (China) 体温:温度:就医过程持续时间^第一:^患者:定量型:
Synonyms: 一般体温 体温 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 就医;就医过程 物体 第一个;第一次;首个;首次 身体温度

Example Units

Unit Source
Cel;[degF] Example UCUM Units

11449-6 Pregnancy status - Reported

Term Description

Patient's pregnancy status (e.g., pregnant, not pregnant), as reported by the patient or the patient's proxy.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Pregnancy status
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
Reported

Additional Names

Short Name
Pregnancy status Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Change Reason
10/2016: Added term description and example answer list; Updated Property to Find to align with similar terms
Order vs. Observation
Observation
Common Test Rank Get Info
4559

Example Answer List LL4129-4

Answer Code Score Answer ID
Pregnant LA15173-0
Not pregnant LA26683-5
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) LA4489-6

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
68991-9 Epidemiologically important information for public health reporting panel
47245-6 HIV treatment form Document
89543-3 Laboratory ask at order entry panel

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Schwangerschafts-St.
es-AR Spanish (Argentina) estado de embarazo:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:informado
es-MX Spanish (Mexico) Estado de embarazo:Tipo:Punto temporal:^ Paciente:Nominal:Reported
it-IT Italian (Italy) Gravidanza, stato:Osservazione:Pt:^Paziente:Nom:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) Stato gravidico
nl-NL Dutch (Netherlands) zwangerschapsstatus:bevinding:moment:^patiënt:nominaal:rapportage
pt-BR Portuguese (Brazil) Estado de gravidez:Imp:Pt:^Paciente:Nom:Relatado
Synonyms: Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal; Gestation; Gravida; Gestations; Pregnancies
ru-RU Russian (Russian Federation) Беременность статус:Находка:ТчкВрм:^Пациент:Ном:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 妊娠状态:发现:时间点:^患者:名义型:报告法
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 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 怀孕;怀孕期;妊娠期 怀孕状态;妊娠状况;妊娠情况 时刻;随机;随意;瞬间 状况;情况 病史与体格检查

11368-8 Illness or injury onset date and time

Fully-Specified Name

Component
Illness or injury onset date and time
Property
TmStp
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Illness or injury onset date and time

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Common Test Rank Get Info
273

Member of these Panels

LOINC Long Common Name
78000-7 Case notification panel [CDC.PHIN]
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
68991-9 Epidemiologically important information for public health reporting panel
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
89724-9 Minimum Data Set (MDS) for Public Health Emergency Operations Centers (EOC) [CDC Emergency Operations Centers]
62863-6 PhenX domain - Infectious diseases and immunity
81959-9 Public health laboratory ask at order entry panel
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Fecha y hora de aparición de la enfermedad o lesión:TmStp:Punto temporal:^ Paciente:Cuantitativo:
es-AR Spanish (Argentina) fecha/hora del inicio de la enfermedad/aparición de la lesión traumática:marca de tiempo:fecha y hora:punto en el tiempo:^paciente:cuantitativo:
fr-CA French (Canada) Condition médicale date et heure du début:Estampille temporelle:Temps ponctuel:^Patient:Quantitatif:
fr-BE French (Belgium) Condition médicale date et heure du début:Estampille temporelle:Temps ponctuel:^Patient:Quantitatif:
it-IT Italian (Italy) Malattia o lesione, data e ora insorgenza:TmStp:Pt:^Paziente:Qn:
Synonyms: Anamnesi Data e ora comparsa malattia o lesione paziente Punto nel tempo (episodio) Time stamp (Data e Ora)
pt-BR Portuguese (Brazil) Data e tempo do inicio da doença ou lesão:TmStp:Pt:^Paciente:Qn:
Synonyms: Time stamp; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Заболевание или травма начало дата и время:TmStp:ТчкВрм:^Пациент:Колич:
Synonyms: Time Stamp (Дата и Время) Дата и время начала заболевания или травмы Количественный Точка во времени;Момент
zh-CN Chinese (China) 疾病或损伤起始日期与时间:时间戳:时间点:^患者:定量型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印时戳;时标;时间戳(日期与时间);时间标记;计时标记 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 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 日子;几号 日期与时间;日期及时间;日期时间 时刻;随机;随意;瞬间 时间(如秒);时间(如秒数) 疾病或损伤起始(开始、发病、发生、发作、开端、肇始)日期与时间;疾病或损伤发病日期与时间;疾病或损伤起病日期与时间;疾病或损伤发作日期与时间;疾病或损伤开始日期与时间;疾病或损伤初起日期与时间 病史与体格检查

11374-6 Injury incident description Narrative

Fully-Specified Name

Component
Injury incident description
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Injury incident description

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
86345-6 U.S. standard certificate of death - recommended 2003 revision set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Descripción del incidente de la lesión:Tipo:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) descripción del evento que causó la lesión traumática:hallazgo:punto en el tiempo:^paciente:Narrativo:
it-IT Italian (Italy) Lesione, descrizione incidente:Osservazione:Pt:^Paziente:Nar:
Synonyms: Descrizione incidente lesivo Emergenza (DEEDS - Data Elements for Emergency Dep Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Травма инцидент описание:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описание обстоятельств травмы Описательный Точка во времени;Момент
zh-CN Chinese (China) 损伤事件描述:发现:时间点:^患者:叙述型:
Synonyms: ED 伤害事件描述;受伤事件描述;损伤意外事件描述;损伤偶然事件描述;损伤事故描述;损伤事件说明 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 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 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 时刻;随机;随意;瞬间

11373-8 Injury cause

Fully-Specified Name

Component
Injury cause
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Injury cause

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.27

Example Answer List LL4936-2

Answer Code Score Answer ID
Animal bite LA17118-3
Device related LA28743-5
Disease related LA28744-3
Human bite LA28745-0
Insect bite LA28746-8
Moisture related LA28747-6
Pressure point related LA28748-4
Self inflicted LA28749-2
Shearing force injury LA28750-0
Trauma LA17058-1

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
39135-9 Wound assessment panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Causa de la lesión:Tipo:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) causa de la lesión traumática:tipo:punto en el tiempo:^paciente:Nominal:
it-IT Italian (Italy) Lesione, causa:Tipo:Pt:^Paziente:Nom:
Synonyms: Causa di lesione;Causa di ferita Emergenza (DEEDS - Data Elements for Emergency Dep paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Causa de lesão:Tipo:Pt:^Paciente:Nom:
Synonyms: Typ; Point in time; Random; Nominal; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Травма причина:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Причина травмы Точка во времени;Момент
zh-CN Chinese (China) 损伤原因:类型:时间点:^患者:名义型:
Synonyms: ED 伤害原因;损害原因;受伤原因 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 型 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 时刻;随机;随意;瞬间

11376-1 Injury location

Fully-Specified Name

Component
Injury location
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Injury location

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.34

Example Answer List LL1051-3

Answer Code Score Answer ID
Home LA14084-0
Residential institution LA14085-7
School LA14086-5
Public institution LA14087-3
Sports or recreational area LA14088-1
Street or highway LA14089-9
Trade or service area LA14090-7
Industrial or construction area LA14091-5
Farm LA14092-3
Unspecified LA14093-1

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Ubicación de la lesión:Tipo:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) localización de lesión traumática:tipo:punto en el tiempo:^paciente:Nominal:
it-IT Italian (Italy) Lesione, posizione:Tipo:Pt:^Paziente:Nom:
Synonyms: Emergenza (DEEDS - Data Elements for Emergency Dep paziente Posizione della lesione;Posizione della ferita Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Localização da lesão:Tipo:Pt:^Paciente:Nom:
Synonyms: Typ; Point in time; Random; Nominal; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Травма локализация:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 损伤地点:类型:时间点:^患者:名义型:
Synonyms: ED 伤害地点;受伤地点;损伤位置(地点、定位、地方、地理位置、工作地点、场所);损伤发生地;损伤发生场所 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 地点;场所;部位;定位;地方 型 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 时刻;随机;随意;瞬间

11372-0 Injury associated activity

Fully-Specified Name

Component
Injury associated activity
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Injury associated activity

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.70
Change Reason
Release 2.70: ANSWER_LIST_TYPE: The NORMATIVE binding was for a specific use-case. This binding is applied in the context of the associated panel (collection).; AnswerListId: Updated answer list to include additional examples. ;

Normative Answer List LL495-3

Answer Code Score Answer ID
Sports 10 LA9373-7
Leisure 20 LA9374-5
Paid work 30 LA9375-2
Unpaid work 40 LA9376-0
Educational activity 50 LA9377-8
Vital activity 60 LA9378-6
Other specified activity 88 LA9379-4
Unknown activity 99 LA9380-2

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Actividad asociada a lesiones:Tipo:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) actividad asociada a la lesión traumática:tipo:punto en el tiempo:^paciente:Nominal:
it-IT Italian (Italy) Lesione, attività associata:Tipo:Pt:^Paziente:Nom:
Synonyms: Attività associata a lesione;Attività associata a Emergenza (DEEDS - Data Elements for Emergency Dep paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Lesão associada à atividade:Tipo:Pt:^Paciente:Nom:
Synonyms: Movements; Typ; Point in time; Random; Nominal; Assoc; Actvty; Activ; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Травма связанная деятельность:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Деятельность, связанная с травмой Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 与损伤相关联的活动:类型:时间点:^患者:名义型:
Synonyms: ED 与损伤相关的活动;损伤相关的活动;与损伤(伤害、损害、受伤)相关联的活动 关联的 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 型 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 时刻;随机;随意;瞬间 有联系的 活动 相关的

11375-3 Injury intent

Fully-Specified Name

Component
Injury intent
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Injury intent

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.34

Example Answer List LL1052-1

Answer Code Score Answer ID
Unintentional LA14094-9
Intentional self-inflicted confirmed LA14095-6
Intentional self-inflicted suspected LA14096-4
Assault confirmed LA14097-2
Assault suspected LA14098-0
Legal intervention LA14099-8
Undetermined LA14100-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) LA4489-6

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Intención de lesión:Tipo:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) intento de lesión traumática:tipo:punto en el tiempo:^paciente:Nominal:
it-IT Italian (Italy) Lesione, intento:Tipo:Pt:^Paziente:Nom:
Synonyms: Emergenza (DEEDS - Data Elements for Emergency Dep Intento lesivo paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Lesão intencional:Tipo:Pt:^Paciente:Nom:
Synonyms: Typ; Point in time; Random; Nominal; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Травма намерение:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Преднамеренность повреждения Точка во времени;Момент
zh-CN Chinese (China) 损伤意图:类型:时间点:^患者:名义型:
Synonyms: ED 伤害意图;受伤意图;损伤目的 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 型 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 时刻;随机;随意;瞬间

11457-9 Safety equipment used

Fully-Specified Name

Component
Safety equipment used
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Safety equipment used

Basic Attributes

Class
ED
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63
Change Reason
Updated Answer list type from "NORMATIVE" to "EXAMPLE" since this concept is not bound to the existing answer list.

Example Answer List LL496-1

Answer Code Score Answer ID
Shoulder belt 010 LA9381-0
Lap belt 020 LA9382-8
Seat belt, not otherwise specified 030 LA9383-6
Driver's front air bag 040 LA9384-4
Passenger's front air bag 050 LA9385-1
Front air bag, not otherwise specified 060 LA9386-9
Side air bag 070 LA9387-7
Air bag, not otherwise specified 080 LA9388-5
Child safety seat 090 LA9389-3
Helmet 100 LA9390-1
Eye protection 110 LA9391-9
Protective clothing 120 LA9392-7
Personal flotation device 130 LA9393-5
Other protective gear 888 LA9394-3

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) equipo de seguridad utililzado:tipo:punto en el tiempo:^paciente:Nominal:
es-MX Spanish (Mexico) Equipo de seguridad utilizado:Tipo:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Dispositivi di sicurezza usati:Tipo:Pt:^Paziente:Nom:
Synonyms: Emergenza (DEEDS - Data Elements for Emergency Dep paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Uso de equipamento de segurança:Tipo:Pt:^Paciente:Nom:
Synonyms: Typ; Point in time; Random; Nominal; EMERGENCY DEPARTMENT (DEEDS); DEEDS; EMERGENCY DEPARTMENT (DEEDS)
ru-RU Russian (Russian Federation) Защитное устройство использовано:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 所使用的安全装备:类型:时间点:^患者:名义型:
Synonyms: ED 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 型 安全设备;安全器具;保护装置;安全用品 急诊科 急诊科(DEEDS)变量;DEEDS 变量;急诊;急诊科;Emergency Department;ED;急诊科(急诊科系统代码之数据元素)变量;急诊科(急诊科系统代码之数据元素)指标;急诊科(美国CDC急诊科系统代码之数据元素)指标;急诊科指标 急诊科(Emergency Department,ED) 急诊部 所使用的安全设备;所使用的安全器具;所使用的保护装置;所使用的安全用品;已使用的安全装备;所采用的安全装备 时刻;随机;随意;瞬间

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.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Information source
Property
Type
Time
Pt
System
{system}
Scale
Nom
Method

Additional Names

Short Name
Source of info

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.21
Last Updated
Version 2.73
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

LOINC Long Common Name
78000-7 Case notification panel [CDC.PHIN]
85735-9 Congenital rubella case report panel
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
71531-8 ESRD hospitalization panel
89724-9 Minimum Data Set (MDS) for Public Health Emergency Operations Centers (EOC) [CDC Emergency Operations Centers]
88028-6 Tobacco use panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Informationsquelle:Typ:Zeitpunkt:{System}:Nominal:
es-MX Spanish (Mexico) Fuente de información:Tipo:Punto temporal:{sistema}:Nominal:
it-IT Italian (Italy) Fonte informativa:Tipo:Pt:{system}:Nom:
Synonyms: Documentazione miscellanea Miscellanea Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Информация источник:Тип:ТчкВрм:{система}:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 信息来源:类型:时间点:{系统}:名义型:
Synonyms: {体系} 信息源;信息源头;资讯来源;信源;资讯源 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 型 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 源

10154-3 Chief complaint Narrative - Reported

Term Description

Chief complaint records the patient's primary complaint (the patient's own description).
Source: Regenstrief LOINC

Fully-Specified Name

Component
Chief complaint
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Reported

Additional Names

Short Name
Chief complaint Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
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
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
82811-1 Nurse summary note - recommended sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Queja principal:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
es-AR Spanish (Argentina) motivo de consulta principal:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-BE French (Belgium) Plainte principale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Disturbo principale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) belangrijkste klacht:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Основная жалоба:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 主诉:发现:时间点:^患者:叙述型:报告法
Synonyms: 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

10164-2 History of Present illness Narrative

Term Description

History of present illness describes the history related to the reason for a given procedure. It contains the historical details leading up to and pertaining to the patient's current complaint or reason for seeking medical care. Because history of present illness can include past surgical history and other procedures, the Procedure History section may be included under the History of Present Illness section or it may stand alone as its own section.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Present illness
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Pres illness

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
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;

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
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
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
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
de-DE German (Germany) Anamnese der aktuellen Krankheit:Anamnese:Zeitpunkt:^Patient:Freitext:
es-MX Spanish (Mexico) Enfermedad presente:Hx:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) antecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
it-IT Italian (Italy) Malattia attuale:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) huidige ziekte:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
zh-CN Chinese (China) 现有疾病:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 现病史;目前疾病;当前疾病;现病 病史与体格检查

11450-4 Problem list - Reported

Fully-Specified Name

Component
Problem list
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
Reported

Additional Names

Short Name
Problem list Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Common Test Rank Get Info
9889

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel
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
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
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
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
82811-1 Nurse summary note - recommended 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
74449-0 Patient plan of care - recommended IHE set
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
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
de-DE German (Germany) Problemliste:Befund:Zeitpunkt:^Patient:Nominal:Berichtet
es-AR Spanish (Argentina) lista de problemas:hallazgo:punto en el tiempo:^paciente:Nominal:informado
es-MX Spanish (Mexico) Lista de problemas:Tipo:Punto temporal:^ Paciente:Nominal:Reported
fr-BE French (Belgium) Liste de problèmes:Observation:Temps ponctuel:^Patient:Nominal:Rapporté
fr-CA French (Canada) Liste des problèmes:Observation:Temps ponctuel:^Patient:Nominal:Rapporté
it-IT Italian (Italy) Lista dei problemi:Osservazione:Pt:^Paziente:Nom:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) probleemlijst:bevinding:moment:^patiënt:nominaal:rapportage
pt-BR Portuguese (Brazil) Lista de problemas:Achado:Pt:^Paciente:Nom:Relatado
Synonyms: Finding; Findings; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Проблем список:Находка:ТчкВрм:^Пациент:Ном:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Номинальный;Именной Список проблем Точка во времени;Момент
zh-CN Chinese (China) 问题列表:发现:时间点:^患者:名义型:报告法
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 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 时刻;随机;随意;瞬间 病史与体格检查 问题目录;问题清单 难题;困难;棘手问题;麻烦;乱子;疑难问题;疑难

11348-0 History of Past illness Narrative

Term Description

History of past illness describes the history related to their current complaints, problems, or diagnoses.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Past illness
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Past illness

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
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;

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
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
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
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
de-DE German (Germany) Anamnese früherer Krankheiten:Anamnese:Zeitpunkt:^Patient:Freitext:
es-MX Spanish (Mexico) Enfermedad pasada:Hx:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) antecedentes de enfermedades pasadas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-BE French (Belgium) Anamnèse. Maladies antérieures:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Malattie pregresse:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) ziektegeschiedenis:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История предыдущих заболеваний:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез заболеваний История Описательный Точка во времени;Момент
zh-CN Chinese (China) 既往病史:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 既往疾病史;既往疾病历史 时刻;随机;随意;瞬间 病史与体格检查

29762-2 Social history Narrative

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.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Social history
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Social Hx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
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
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
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
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
de-DE German (Germany) Sozialanamnese:Befund:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedentes sociales:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Historia social:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Histoire sociale:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Storia sociale:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) sociale geschiedenis:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Histórico social:Achado:Pt:^Paciente:Nar:
Synonyms: ; Social Hx; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Социальная история:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Социальный анамнез Точка во времени;Момент
zh-CN Chinese (China) 社会史:发现:时间点:^患者:叙述型:
Synonyms: 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 时刻;随机;随意;瞬间 病史与体格检查 社会历史

11380-3 Marital status and living arrangements Narrative - Reported

Fully-Specified Name

Component
Marital status and living arrangements
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Reported

Additional Names

Short Name
Marital status+living arrang

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.48

HL7® Attributes

HL7® Field ID
PID-16

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Estado civil y arreglos de vivienda:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
es-AR Spanish (Argentina) estado civil y situación habitacional:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-BE French (Belgium) Status marital et mode de vie:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Stato civile e tenore di vita:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Семейное положение и жилищные условия:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Точка во времени;Момент
zh-CN Chinese (China) 婚姻状况与生活安排:发现:时间点:^患者:叙述型:报告法
Synonyms: 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 在世;生存着的;有生命的;在活动中;没死 婚姻状态;婚否;婚姻情况 婚姻状态与生活安排;婚姻情况与生活安排 时刻;随机;随意;瞬间 状况;情况 病史与体格检查

11294-6 Current employment Narrative - Reported

Fully-Specified Name

Component
Current employment
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Reported

Additional Names

Short Name
Current employment Reported

Basic Attributes

Class
ADMIN.PATIENT.DEMOG
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.66

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Member of these Groups Get Info

LOINC Group Group Name
LG51306-5 SDOH

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Empleo actual:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
es-AR Spanish (Argentina) empleo actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-BE French (Belgium) Emploi actuel:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Impiego attuale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Amministrativo Dati demografici del paziente Lavoro attuale Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Текущая занятость:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Занятость в настоящее время Описательный Точка во времени;Момент
zh-CN Chinese (China) 当前职位:发现:时间点:^患者:叙述型:报告法
Synonyms: 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 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 目前工作;现任;现职;当前职业;当前工作;当前就职;当前(目前)就业(聘用、雇佣、从业、应聘)情况 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).人口统计学信息(人口统计学、人口统计、人口统计数据、人口统计学数据、人口统计特征、人口统计学特征、个人基本信息、人员基本信息、个人基本资料、个人基本数据)

11340-7 History of Occupation Narrative

Part Descriptions

LP133724-7   Occupation
The type of work done by the subject during his or her working life. Source: Regenstrief LOINC

Fully-Specified Name

Component
Occupation
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Occupation

Basic Attributes

Class
ADMIN.PATIENT.DEMOG
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.66
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Ocupación:Hx:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) antecedentes laborales:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
it-IT Italian (Italy) Occupazione:Hx:Pt:^Paziente:Nar:
Synonyms: Amministrativo Dati demografici del paziente Paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) beroep:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) Род занятости:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Точка во времени;Момент
zh-CN Chinese (China) 职业:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 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 行业;工作;业务;专业 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).人口统计学信息(人口统计学、人口统计、人口统计数据、人口统计学数据、人口统计特征、人口统计学特征、个人基本信息、人员基本信息、个人基本资料、个人基本数据)

11330-8 History of Alcohol use Narrative

Fully-Specified Name

Component
Alcohol use
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Alcohol use

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
Changed Component from "History of alcohol use" to "Alcohol use", Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Consumo de alcohol:Hx:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) antecedentes de consumo de alcohol:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
it-IT Italian (Italy) Uso di alcol:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) alcoholgebruik:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: alcoholgebruik anamnese
ru-RU Russian (Russian Federation) Употребление алкоголя:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Точка во времени;Момент
zh-CN Chinese (China) 酒精使用:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 喝酒;饮酒;酒精饮用;喝酒情况;饮酒情况;酒精饮用情况;酒精使用情况 时刻;随机;随意;瞬间 病史与体格检查

11287-0 Alcoholic drinks per drinking day - Reported

Fully-Specified Name

Component
Alcoholic drinks per drinking D
Property
NRat
Time
1D
System
^Patient
Scale
Qn
Method
Reported

Additional Names

Short Name
Alcoholic drinks/drinking D Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Common Test Rank Get Info
1144

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Bebidas alcohólicas por consumo D:NRat:1D:^ Paciente:Cuantitativo:Reported
es-AR Spanish (Argentina) tragos con alcohol por día de consumo:índice numérico:1 día:^paciente:cuantitativo:informado
it-IT Italian (Italy) Bevande alcoliche al giorno:NRat:1 gg:^Paziente:Qn:Riportato
Synonyms: 1 giorno; 1 die Anamnesi Drink alcolici al giorno;Unità alcoliche al giorno Indice numerico paziente
nl-NL Dutch (Netherlands) alcoholconsumpties per dag met alcoholgebruik:aantal/tijd:1 dag:^patiënt:kwantitatief:rapportage
Synonyms: 1D alcohol consumpties per D met alcohol gebruik
pt-BR Portuguese (Brazil) Bebidas alcóolicas bebidas por dia:NRat:1D:^Paciente:Qn:Relatado
Synonyms: ; Alcoholic drinks/drinking day; nRate; Number rate; Count/time; 1 day; 24 hours; 24HR; 24H; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Алкогольные напитки в злоупотребление день:КолСкор:1 день:^Пациент:Колич:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Количественный Количество скорость
zh-CN Chinese (China) 每个饮酒日的酒精饮料杯数:计数型速率:1天:^患者:定量型:报告法
Synonyms: 1日;24.0小时;24小时;一天;一日;二十四小时 Rh;Rhesus;恒河猴;猕猴;罗猴 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 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 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 每个饮酒日的酒精饮料杯数(标准杯数、标准饮酒单位数、标准饮酒量、份数、量);每个饮酒日的酒精饮料量 病史与体格检查

Example Units

Unit Source
/d Example UCUM Units
#drinks/day REGENSTRIEF

11286-2 Alcohol binge episodes per month - Reported

Fully-Specified Name

Component
Alcohol binge episodes per M
Property
NRat
Time
1Mo
System
^Patient
Scale
Qn
Method
Reported

Additional Names

Short Name
Alcohol binge episodes/M Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.50

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Episodios de atracones de alcohol por M:NRat:1Mes:^ Paciente:Cuantitativo:Reported
es-AR Spanish (Argentina) episodios de consumo compulsivo de alcohol:índice numérico:1 minuto:^paciente:cuantitativo:informado
it-IT Italian (Italy) Episodi di consumo eccessivo di alcol al mese:NRat:1Mese:^Paziente:Qn:Riportato
Synonyms: 1 mese Anamnesi Episodi di sbronza al mese Indice numerico paziente
pt-BR Portuguese (Brazil) Episódios de bebedeiras ou embriaguez?????:NRat:1Mo:^Paciente:Qn:Relatado
Synonyms: ; Alcohol binge episodes/month; nRate; Number rate; Count/time; 1 month; 30 days; Quantitative; QNT; Quant; Quan; Alc
ru-RU Russian (Russian Federation) Алкоголь злоупотребление эпизодов в месяц:КолСкор:1 месяц:^Пациент:Колич:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Количественный Количество скорость
zh-CN Chinese (China) 每个月的酗酒事件:计数型速率:1个月:^患者:定量型:报告法
Synonyms: 30天;30日;一个月;三十天;三十日 M 型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 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 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 每个月的疯狂饮酒事件;每个月的酒精狂饮事件;每个月的酒精放纵事件;每个月的酒精不节制事件;每个月的放纵狂饮事件;每个月的放纵大喝事件 病史与体格检查

Example Units

Unit Source
{#}/mo Example UCUM Units

11366-2 History of Tobacco use Narrative

Fully-Specified Name

Component
Tobacco use status
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Tobacco use

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.58
Change Reason
Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision; Changed Component from "Tobacco use" to clarify meaning as the status of tobacco use, not the type of tobacco used

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88028-6 Tobacco use panel

Member of these Groups Get Info

LOINC Group Group Name
LG41856-2 Smoking-related terms

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Estado de consumo de tabaco:Hx:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) antecedentes de tabquismo:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-CA French (Canada) Habitudes tabagiques:Histoire:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Status d'uso del tabacco:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) tabaksgebruik:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
zh-CN Chinese (China) 烟草使用状况:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 烟草使用(烟草吸食、吸烟、抽烟、用烟)状况(状态、情况) 烟草吸食;吸烟;抽烟;用烟 状况;情况 病史与体格检查

8663-7 Cigarettes smoked current (pack per day) - Reported

Fully-Specified Name

Component
Cigarettes smoked.current (pack per day)
Property
NRat
Time
Pt
System
^Patient
Scale
Qn
Method
Reported

Additional Names

Short Name
Cigs smoked (pack/day) nRate Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.73
Common Test Rank Get Info
3283

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88028-6 Tobacco use panel

Member of these Groups Get Info

LOINC Group Group Name
LG41856-2 Smoking-related terms

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) cigarrillos fumados.actualmente (paquetes por día):número:punto en el tiempo:^paciente:cuantitativo:informado
es-MX Spanish (Mexico) Cigarrillos fumados corriente (paquete por día):NRat:Punto temporal:^ Paciente:Cuantitativo:Reported
it-IT Italian (Italy) Sigarette fumate.corrente (pacchetti al giorno):NRat:Pt:^Paziente:Qn:Riportato
Synonyms: Anamnesi Indice numerico paziente Punto nel tempo (episodio) Sigarette correntemente fumate (pacchetti al giorn
nl-NL Dutch (Netherlands) sigarettengebruik actueel (pakjes per dag):aantal/tijd:moment:^patiënt:kwantitatief:rapportage
pt-BR Portuguese (Brazil) Cigarros fumados.atual (maços por dia):NRat:Pt:^Paciente:Qn:Relatado
Synonyms: ; Cigarettes smoked (pack/day); nRate; Number rate; Count/time; Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Сигарет выкуривается.текущий (пачек в день):КолСкор:ТчкВрм:^Пациент:Колич:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Количественный Количество скорость Точка во времени;Момент
zh-CN Chinese (China) 所抽香烟.当前 (每天包数):计数型速率:时间点:^患者:定量型:报告法
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 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 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 所抽(吸、抽吸)香烟(卷烟、纸烟).当前 (每天盒数);当前每日所吸香烟包数;当前每天所抽香烟盒数 日;昼;白天;周几;星期几 时刻;随机;随意;瞬间 病史与体格检查

Example Units

Unit Source
{#}/d Example UCUM Units

8664-5 Cigarettes smoked total (pack per year) - Reported

Fully-Specified Name

Component
Cigarettes smoked.total (pack per year)
Property
NRat
Time
Pt
System
^Patient
Scale
Qn
Method
Reported

Additional Names

Short Name
Cigs smoked (pack/year) nRate Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.48

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Member of these Groups Get Info

LOINC Group Group Name
LG41856-2 Smoking-related terms

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) cigarrillos fumados.total (paquetes por año):número:punto en el tiempo:^paciente:cuantitativo:informado
es-MX Spanish (Mexico) Cigarrillos fumados total (paquete por año):NRat:Punto temporal:^ Paciente:Cuantitativo:Reported
it-IT Italian (Italy) Sigarette fumate.totale (pacchetti all'anno):NRat:Pt:^Paziente:Qn:Riportato
Synonyms: Anamnesi Indice numerico paziente Punto nel tempo (episodio) Totale sigarette fumate (pacchetti all''anno)
nl-NL Dutch (Netherlands) sigarettengebruik totaal (pakjes per jaar):aantal/tijd:moment:^patiënt:kwantitatief:rapportage
pt-BR Portuguese (Brazil) Cigarros fumados.total (maços por ano):NRat:Pt:^Paciente:Qn:Relatado
Synonyms: ; Cigarettes smoked (pack/year); nRate; Number rate; Count/time; Point in time; Random; Quantitative; QNT; Quant; Quan; Tot; Totl
ru-RU Russian (Russian Federation) Сигарет выкуривается.общий (пачек в год):КолСкор:ТчкВрм:^Пациент:Колич:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Количественный Количество скорость Точка во времени;Момент
zh-CN Chinese (China) 所抽香烟.总计 (每年包数):计数型速率:时间点:^患者:定量型:报告法
Synonyms: 全体数量 全部 共计 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 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 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 总 总和 总数 总量 总额 所抽(吸、抽吸)香烟(卷烟、纸烟).总计 (每年盒数);每年所抽香烟总盒数;每年所吸香烟总包数 时刻;随机;随意;瞬间 汇总 病史与体格检查

Example Units

Unit Source
{#}/a Example UCUM Units

11342-3 History of Other nonmedical drug use Narrative

Fully-Specified Name

Component
Other nonmedical drug use
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Other nonmedical drug use

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Uso de otras drogas no médicas:Hx:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) antecedentes de consumo de otras drogas de uso no terapéutico:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-BE French (Belgium) Anamnèse. Utilisation de drogues nonmédicales:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Altro uso non medico di droghe:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) overig drugsgebruik:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История немедикаментозных лекарств употребления:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Наркотик Описательный Точка во времени;Момент
zh-CN Chinese (China) 其他非医用毒品使用史:历史记录:时间点:^患者:叙述型:
Synonyms: 其他的 其他非医用毒品使用历史;其他非药用毒品使用史 其它 其它的 别的 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 另外的 时刻;随机;随意;瞬间 毒品 毒品;麻醉药;麻醉品;麻药;兴奋剂;药品 毒品类 病史与体格检查 药品类 药物 药物(毒品、麻醉药、麻醉品、麻药、兴奋剂、药品)使用(利用、服用) 药物类

82589-3 Highest level of education

Part Descriptions

LP72877-1   Highest level of education
The highest level of education attained. Source: Centers for Disease Control and Prevention

Fully-Specified Name

Component
Highest level of education
Property
Hx
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Highest level of educ

Basic Attributes

Class
ADMIN.PATIENT.DEMOG
Type
Clinical
First Released
Version 2.58
Last Updated
Version 2.73
Change Reason
Removed the Method of Reported
Order vs. Observation
Observation
Common Test Rank Get Info
294

Normative Answer List LL7-6

Answer Code Score Answer ID
No schooling 1 LA35-1
8th grade/less 2 LA36-9
9-11 grades 3 LA37-7
High school 4 LA38-5
Technical or trade school 5 LA39-3
Some college 6 LA40-1
Bachelor's degree 7 LA41-9
Graduate degree 8 LA42-7

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
45969-3 Deprecated MDS background information at admission form - version 2.0
99192-7 Patient-reported outcomes with LASIK - pre-operative panel [Patient reported outcomes with LASIK]
93025-5 Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]
98154-8 SARS-CoV-2-related socioeconomic questionnaire for adults

Member of these Groups Get Info

LOINC Group Group Name
LG51306-5 SDOH

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) El mas alto nivel de educación:Hx:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Livello più elevato di istruzione:Hx:Pt:^Paziente:Ord:
Synonyms: Amministrativo Dati demografici del paziente Paziente Punto nel tempo (episodio) Storia;Anamnesi
ru-RU Russian (Russian Federation) Уровень образования:Hx:ТчкВрм:^Пациент:Пор:
Synonyms: История Порядковый Точка во времени;Момент
zh-CN Chinese (China) 文化程度:历史记录:时间点:^患者:序数型:
Synonyms: 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 教育程度;教育水平;教育等级;受教育程度 时刻;随机;随意;瞬间 程度 等级 级 级别 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).人口统计学信息(人口统计学、人口统计、人口统计数据、人口统计学数据、人口统计特征、人口统计学特征、个人基本信息、人员基本信息、个人基本资料、个人基本数据)

11350-6 History of Sexual behavior Narrative

Fully-Specified Name

Component
Sexual behavior
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Sexual behavior

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Comportamiento sexual:Hx:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) antecedentes de conducta sexual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-BE French (Belgium) Anamnèse. Comportement sexuel:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Comportamento sessuale:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
ru-RU Russian (Russian Federation) История полового поведения:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Половой анамнез Точка во времени;Момент
zh-CN Chinese (China) 性行为史:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 性行为历史 时刻;随机;随意;瞬间 病史与体格检查

10182-4 History of Travel Narrative

Fully-Specified Name

Component
Travel
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Travel

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
89543-3 Laboratory ask at order entry panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Viaje:Hx:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) antecedentes de viajes realizados:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
it-IT Italian (Italy) Viaggio:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
zh-CN Chinese (China) 旅行:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 旅游;出行;长途行走;游历 时刻;随机;随意;瞬间 病史与体格检查

10157-6 History of family member diseases Narrative

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.
Source: Regenstrief LOINC

Fully-Specified Name

Component
History of family member diseases
Property
Hx
Time
Pt
System
^Family member
Scale
Nar
Method

Additional Names

Short Name
Family member diseases Hx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73
Change Reason
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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
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
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
35089-2 History and physical panel
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
35090-0 Patient history
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
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) Historia de enfermedades de miembros de la familia:Hx:Punto temporal:^ Miembro de la familia:Narrativo:
es-AR Spanish (Argentina) antecedentes de enfermedades en miembros familiares:hallazgo:punto en el tiempo:familia:Narrativo:informado
fr-BE French (Belgium) Anamnèse. Maladies dans la famille:Hx:Temps ponctuel:^membre de famille:Narratif:
fr-CA French (Canada) Antécédents familiaux:Histoire:Temps ponctuel:^membre de famille:Narratif:
it-IT Italian (Italy) Storia di malattie di membri familiari:Hx:Pt:^membro della famiglia:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Storia di malattie di membri della famiglia Storia;Anamnesi
nl-NL Dutch (Netherlands) geschiedenis van ziekte binnen de familie:voorgeschiedenis:moment:^familielid:tekstueel:
Synonyms: anamnese ziekte in familieanamnese
ru-RU Russian (Russian Federation) История член семьи заболевания:Hx:ТчкВрм:^семьи член:Опис:
Synonyms: История Описательный Семейный анамнез заболеваний Точка во времени;Момент
zh-CN Chinese (China) 家族成员疾病史:历史记录:时间点:^家庭成员:叙述型:
Synonyms: 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 家人;家族成员;超系统 - 家庭成员 家庭 家族成员病史;家属疾病史;家属病史;家庭成员疾病史;家庭成员病史 时刻;随机;随意;瞬间 病史与体格检查

10187-3 Review of systems Narrative - Reported

Term Description

The Review of systems section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Review of systems
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Reported

Additional Names

Short Name
Review of systems

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

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
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
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) Revisión de sistemas:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
es-AR Spanish (Argentina) revisión de sistemas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-BE French (Belgium) Revue des systèmes:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Esame di apparati:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) beoordeling van systemen:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Исследование по системам:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Точка во времени;Момент
zh-CN Chinese (China) 系统评审:发现:时间点:^患者:叙述型:报告法
Synonyms: 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 时刻;随机;随意;瞬间 病史与体格检查 系统回顾;系统审核

10171-7 History of Eyes disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Eyes
Scale
Nar
Method

Additional Names

Short Name
Hx of Eyes disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Ojos:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:ojos:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Occhi:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:眼睛类:叙述型:
Synonyms: 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 症状和疾病 症状类 眼睛(复数);目;眼;眼睛;眼部

11354-8 History of Ears and Nose and Sinuses and Mouth and Throat disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Ears & Nose & Sinuses & Mouth & Thr
Scale
Nar
Method

Additional Names

Short Name
Hx of ENSMT disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Oídos, nariz, senos nasales, boca y trombocitopenia:Narrativo:
es-AR Spanish (Argentina) oídos, nariz, senos paranasales, boca y fauces:hallazgo:punto en el tiempo:EARS & NOSE & SINUSES & MOUTH & THR:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Orecchie & naso & seni & bocca & gola:Nar:
Synonyms: Anamnesi Orecchie e Naso e Seni e Bocca e Gola Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:耳与鼻与附鼻窦类与口与咽喉:叙述型:
Synonyms: 副鼻窦类(副鼻窦、鼻窦、鼻窦类、窦、窦类);窦(复数);窦道(复数);附鼻窦(复数) 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 嘴 时刻;随机;随意;瞬间 病史与体格检查 症状和疾病 症状类 耳 & 鼻 & 附鼻窦类(副鼻窦、鼻窦、鼻窦类、窦、窦类) & 口 & 咽喉;耳+鼻+鼻窦+口+咽喉;耳与鼻与鼻窦与口与咽喉;耳朵 & 鼻子 & 鼻窦 & 口 & 咽喉;耳朵+鼻子+鼻窦+口+咽喉;耳朵与鼻子与鼻窦与口与咽喉;耳、鼻、附鼻窦类、口与咽喉 鼻部

10168-3 History of Cardiovascular system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Cardiovascular system
Scale
Nar
Method

Additional Names

Short Name
Hx of CVS disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
80346-0 Nursing physiologic assessment panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema cardiovascular:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:aparato cardiovascular:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparato cardiovascolare:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Sistema cardiovascolare Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:心血管系统:叙述型:
Synonyms: 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 症状和疾病 症状类

10177-4 History of Respiratory system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Respiratory system
Scale
Nar
Method

Additional Names

Short Name
Hx of Respiratory disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema respiratorio:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:aparato respiratorio:Narrativo:informado
fr-CA French (Canada) Symptômes et maladies:Histoire:Temps ponctuel:Système respiratoire:Narratif:
Synonyms: Antécédents médicaux
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparato respiratorio:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:呼吸系统:叙述型:
Synonyms: 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 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 时刻;随机;随意;瞬间 病史与体格检查 症状和疾病 症状类

11355-5 History of Gastrointestinal system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Gastrointestinal system
Scale
Nar
Method

Additional Names

Short Name
Hx of GI disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema gastrointestinal:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:aparato digestivo:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparato gastrointestinale:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:胃肠道系统:叙述型:
Synonyms: 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 消化系统;消化道系统 病史与体格检查 症状和疾病 症状类

11356-3 History of Genitourinary systems disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Genitourinary systems
Scale
Nar
Method

Additional Names

Short Name
Hx of GU disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistemas genitourinarios:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:aparatos genitourinarios:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparati genito urinari:Nar:
Synonyms: Anamnesi Apparati genito-urinari Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:泌尿生殖系统类:叙述型:
Synonyms: 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 泌尿生殖系统(复数);泌尿生殖系统(泌尿生殖、生殖泌尿、生殖泌尿系统、泌尿生殖道、生殖泌尿道);泌尿生殖;生殖泌尿;生殖泌尿系统;泌尿生殖道;生殖泌尿道 病史与体格检查 症状和疾病 症状类

10176-6 History of Reproductive system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Reproductive system
Scale
Nar
Method

Additional Names

Short Name
Hx of Reproductive disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema reproductivo:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:sistema reproductor:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparato riproduttivo:Nar:
Synonyms: Anamnesi Apparato riproduttore Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:生殖系统:叙述型:
Synonyms: 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 症状和疾病 症状类

10181-6 History of Urinary tract disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Urinary tract
Scale
Nar
Method

Additional Names

Short Name
Hx of Urinary disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Tracto urinario:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:vías urinarias:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Tratto urinario:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:尿路:叙述型:
Synonyms: 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 泌尿道 病史与体格检查 症状和疾病 症状类

10173-3 History of Musculoskeletal system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Musculoskeletal system
Scale
Nar
Method

Additional Names

Short Name
Hx of Musculoskeletal disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema musculoesquelético:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:sistema musculoesquelético:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparato muscolo-scheletrico:Nar:
Synonyms: Anamnesi Apparato muscolo scheletrico Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:肌肉骨骼系统:叙述型:
Synonyms: 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 症状和疾病 症状类 肌肉-骨骼系统

11357-1 History of Integumentary system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Integumentary system
Scale
Nar
Method

Additional Names

Short Name
Hx of Integumentary disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema tegumentario:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:sistema tegumentario:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparato tegumentario:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:皮肤系统:叙述型:
Synonyms: 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 外皮系统 时刻;随机;随意;瞬间 病史与体格检查 症状和疾病 症状类

10178-2 History of Skin disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Skin
Scale
Nar
Method

Additional Names

Short Name
Hx of Skin disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Piel:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:piel:Narrativo:informado
fr-CA French (Canada) Symptômes et maladies:Histoire:Temps ponctuel:Peau:Narratif:
Synonyms: Antécédents médicaux
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Pelle:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:皮肤:叙述型:
Synonyms: 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 症状和疾病 症状类 皮;肤;表皮

11353-0 History of Breasts disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Breasts
Scale
Nar
Method

Additional Names

Short Name
Hx of Brsts disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Pechos:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:mamas:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Mammelle:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Seni Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:乳腺类:叙述型:
Synonyms: 乳腺(复数);乳房;乳房(复数);乳腺;乳腺(乳房) 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 症状和疾病 症状类

8672-8 History of Nervous system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Neurologic system
Scale
Nar
Method

Additional Names

Short Name
Hx of Neurologic disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:sistema neurológico:Narrativo:informado
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema neurológico:Narrativo:
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparato neurologico:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Sistema nervoso Storia;Anamnesi
pt-BR Portuguese (Brazil) Histórico de sintomas & doenças:Achado:Pt:Sistema Neurológico:Nar:Relatado
Synonyms: ; Sx & diseases Hx; Finding; Findings; Point in time; Random; Narrative; Report
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:神经系统:叙述型:
Synonyms: 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 症状和疾病 症状类

11358-9 History of Psychiatric disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Psychiatric
Scale
Nar
Method

Additional Names

Short Name
Hx of Psychiatric disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Psiquiátrico:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:psiquiátrico:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Psichiatrico:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:精神病学:叙述型:
Synonyms: 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 症状和疾病 症状类

10170-9 History of Endocrine system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Endocrine system
Scale
Nar
Method

Additional Names

Short Name
Hx of Endocrine disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema endocrino:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:sistema endocrino:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Apparato endocrino:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:内分泌系统:叙述型:
Synonyms: 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 症状和疾病 症状类

10172-5 History of Hematologic system disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Hematologic system
Scale
Nar
Method

Additional Names

Short Name
Hx of Hematologic disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Sistema hematológico:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:sistema hematológico:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Sistema ematopoietico:Nar:
Synonyms: Anamnesi Apparato ematopoietico Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:造血系统:叙述型:
Synonyms: 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 症状和疾病 症状类 血液学/凝血 血液性

11352-2 History of Allergenic and Immunologic disorders Narrative

Fully-Specified Name

Component
Symptoms & diseases
Property
Hx
Time
Pt
System
Allergic & Immunologic
Scale
Nar
Method

Additional Names

Short Name
Hx of Allergy+Immunologic disorders

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.56
Change Reason
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

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Síntomas y enfermedades:Hx:Punto temporal:Alérgico e inmunológico:Narrativo:
es-AR Spanish (Argentina) antecedentes de síntomas & enfermedades:hallazgo:punto en el tiempo:alérgico e inmunológico:Narrativo:informado
it-IT Italian (Italy) Sintomi & malattie:Hx:Pt:Allergico & immunologico:Nar:
Synonyms: Allergico e Immunologico Anamnesi Punto nel tempo (episodio) Sintomi e malattie Storia;Anamnesi
zh-CN Chinese (China) 症状与疾病:历史记录:时间点:变态反应系统与免疫系统:叙述型:
Synonyms: 免疫 免疫性的 免疫的 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 变应原系统与免疫系统;过敏原系统与免疫系统;过敏反应系统与免疫系统 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 症状和疾病 症状类

29545-1 Physical findings Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
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
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
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
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-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observado
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
fr-BE French (Belgium) Examen physique:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:^Paciente:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 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 时刻;随机;随意;瞬间 病史与体格检查 观测法

10210-3 Physical findings of General status Narrative

Term Description

Physical findings (of general status) describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
General status
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find General status

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
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
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
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
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) Hallazgos físicos:Tipo:Punto temporal:Estatus general:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:estado general:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Stato generale:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Estado geral:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Общий статус:Опис:Наблюдённый
Synonyms: Общее состояние Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:一般状态:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 大体状态;普通状态;总体状态 时刻;随机;随意;瞬间 病史与体格检查 观测法

8893-0 Heart rate Peripheral artery by palpation

Fully-Specified Name

Component
Heart rate
Property
NRat
Time
Pt
System
Peripheral artery
Scale
Qn
Method
Palpation

Additional Names

Short Name
Heart rate Periph a Palpation
Consumer Name Alpha Get Info
Heart rate

Basic Attributes

Class
HRTRATE.MOLEC
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.73
Common Test Rank Get Info
10016

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Member of these Groups Get Info

LOINC Group Group Name
LG33055-1 Heart rate|NRat|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) latido cardíaco:índice numérico:punto en el tiempo:arteria periférica:cuantitativo:palpación
es-MX Spanish (Mexico) Ritmo cardiaco:NRat:Punto temporal:Arteria periférica:Cuantitativo:Palpation
it-IT Italian (Italy) Frequenza cardiaca:NRat:Pt:Arteria periferica:Qn:Palpazione
Synonyms: Frequenza cardiaca - molecolare Indice numerico Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) hartslagfrequentie:aantal/tijd:moment:perifere arterie:kwantitatief:palpatie
pt-BR Portuguese (Brazil) Frequência cardíaca:NRat:Pt:Artéria periferal:Qn:Palpação
Synonyms: ; nRate; Number rate; Count/time; Point in time; Random; Periph a; Art; Quantitative; QNT; Quant; Quan; Pulse; Heart beat; HEART RATE.MOLEC; HEART RATE.MOLEC
zh-CN Chinese (China) 心率:计数型速率:时间点:外周动脉:定量型:触诊法
Synonyms: 切脉;切脉法;切诊;切诊法;扪诊;扪诊法;按诊;按诊法;摸;摸法;触;触诊 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 周围 周围动脉;周边动脉 周围的 周缘 周缘的 周边 周边的 外周的 外围 外围的 外部 外部的 心搏率;心跳速率 时刻;随机;随意;瞬间 末梢 末梢的 特殊心率 边缘 边缘的 速度

Example Units

Unit Source
{beats}/min Example UCUM Units

9279-1 Respiratory rate

Fully-Specified Name

Component
Breaths
Property
NRat
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
Resp rate

Basic Attributes

Class
RESP.ATOM
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73
Common Test Rank Get Info
12

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
75885-4 IEEE 11073 Rosetta panel
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set
80346-0 Nursing physiologic assessment panel
74293-2 Oncology plan of care and summary - recommended CDA set
62611-9 PhenX domain - Respiratory
89694-4 Pulmonary Embolism Severity Index panel [PESI]
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS
34566-0 Vital signs with method details panel
72513-5 Vital signs with smoking status and pain scale [VSP]
34565-2 Vital signs, weight and height panel
67795-5 Vital signs, weight, height, head circumference and oximetry panel HITSP
74728-7 Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel
85353-1 Vital signs, weight, height, head circumference, oxygen saturation and BMI panel

Member of these Groups Get Info

LOINC Group Group Name
LG33054-4 Breaths|NRat|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Atemfrequenz:Anzahl pro Zeit:Zeitpunkt:Respiratorisches System:Quantitativ:
de-AT German (Austria) Synonyms: Atemfrequenz
es-AR Spanish (Argentina) respiraciones:índice numérico:punto en el tiempo:aparato respiratorio:cuantitativo:
es-MX Spanish (Mexico) Respiraciones:NRat:Punto temporal:Sistema respiratorio:Cuantitativo:
it-IT Italian (Italy) Respiri:NRat:Pt:Apparato respiratorio:Qn:
Synonyms: Indice numerico Punto nel tempo (episodio) Respiratorio - atomico
pt-BR Portuguese (Brazil) Respirações:NRat:Pt:Sistema Respiratório:Qn:
Synonyms: ; nRate; Number rate; Count/time; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; Respiratory rate
ru-RU Russian (Russian Federation) Дыхание:КолСкор:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Количество скорость Точка во времени;Момент
zh-CN Chinese (China) 呼吸:计数型速率:时间点:呼吸系统:定量型:
Synonyms: 一般呼吸类指标;一般呼吸系统类指标;呼吸类指标.原子型 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸 呼吸类 呼吸类指标 呼吸系统 呼吸系统类 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 时刻;随机;随意;瞬间

Example Units

Unit Source
{breaths}/min;{counts/min} Example UCUM Units
/MIN REGENSTRIEF

8310-5 Body temperature

Fully-Specified Name

Component
Body temperature
Property
Temp
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Body temperature
Consumer Name Alpha Get Info
Body Temperature

Basic Attributes

Class
BDYTMP.ATOM
Type
Clinical
First Released
Version 1.0h(2)
Last Updated
Version 2.73
Common Test Rank Get Info
49

Member of these Panels

LOINC Long Common Name
35095-9 Body temperature panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
100847-3 Gas and ammonia panel - Arterial blood
93685-6 Gas and Carbon monoxide and Electrolytes panel - Arterial blood
24341-0 Gas and Carbon monoxide panel - Arterial blood
24343-6 Gas and Carbon monoxide panel - Blood
24342-8 Gas and Carbon monoxide panel - Capillary blood
24344-4 Gas and Carbon monoxide panel - Venous blood
99548-0 Gas and electrolytes panel - Arterial blood
24336-0 Gas panel - Arterial blood
51974-4 Gas panel - Arterial cord blood
24338-6 Gas panel - Blood
24337-8 Gas panel - Capillary blood
51973-6 Gas panel - Mixed venous blood
24339-4 Gas panel - Venous blood
51972-8 Gas panel - Venous cord blood
75885-4 IEEE 11073 Rosetta panel
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set
74293-2 Oncology plan of care and summary - recommended CDA set
62611-9 PhenX domain - Respiratory
89694-4 Pulmonary Embolism Severity Index panel [PESI]
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS
34566-0 Vital signs with method details panel
72513-5 Vital signs with smoking status and pain scale [VSP]
34565-2 Vital signs, weight and height panel
67795-5 Vital signs, weight, height, head circumference and oximetry panel HITSP
74728-7 Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel
85353-1 Vital signs, weight, height, head circumference, oxygen saturation and BMI panel
82611-5 Wearable device external physiologic monitoring panel

Member of these Groups Get Info

LOINC Group Group Name
LG33052-8 Body temperature|Temp|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Körpertemperatur:Temperatur:Zeitpunkt:^Patient:Quantitativ:
de-AT German (Austria) Synonyms: Körpertemperatur
es-AR Spanish (Argentina) temperatura corporal:temperatura:punto en el tiempo:^paciente:cuantitativo:
es-MX Spanish (Mexico) Temperatura corporal:Temperatura:Punto temporal:^ Paciente:Cuantitativo:
fr-FR French (France) Température corporelle:Température:Ponctuel:Patient:Numérique:
fr-BE French (Belgium) Température corporelle:Température:Temps ponctuel:^Patient:Quantitatif:
fr-CA French (Canada) Température corporelle:Température:Temps ponctuel:^Patient:Quantitatif:
it-IT Italian (Italy) Temperatura corporea:Temp:Pt:^Paziente:Qn:
Synonyms: paziente Punto nel tempo (episodio) Temperatura Temperatura del corpo - atomica
nl-NL Dutch (Netherlands) lichaamstemperatuur:temperatuur:moment:^patiënt:kwantitatief:
pt-BR Portuguese (Brazil) Temperatura corpórea:Temp:Pt:^Paciente:Qn:
Synonyms: ; Bdy temp; Point in time; Random; Quantitative; QNT; Quant; Quan; bod; Bodies; BODY TEMPERATURE.ATOM; BODY TEMPERATURE.ATOM
ru-RU Russian (Russian Federation) Температура тела:Темп:ТчкВрм:^Пациент:Колич:
Synonyms: Количественный Температура Точка во времени;Момент
tr-TR Turkish (Turkey) Vücut sıcaklığı:Scklk:Zmlı:^Hasta:Kant:
zh-CN Chinese (China) 体温:温度:时间点:^患者:定量型:
Synonyms: 一般体温 体温 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 物体 身体温度

Example Units

Unit Source
Cel Example UCUM Units
Deg C REGENSTRIEF

29463-7 Body weight

Reference Information

Type Source Reference
Citation Regenstrief LOINC Stice, E., Telch, C. F., Rizvi, S. L. (2000). Development and validation of the Eating Disorder Diagnostic Scale: a brief self-report measure of anorexia, bulimia, and binge-eating disorder. Psychological Assessment, 12(2), 123-31.

Fully-Specified Name

Component
Body weight
Property
Mass
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Weight

Basic Attributes

Class
BDYWGT.ATOM
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
44

Member of these Panels

LOINC Long Common Name
58735-2 Alpha-1-Fetoprotein panel - Amniotic fluid
48802-3 Alpha-1-Fetoprotein panel - Serum or Plasma
93478-6 Busulfan area under the curve panel - Plasma
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
86636-8 Family planning report - FPAR 2.0 set
49085-4 First and Second trimester integrated maternal screen panel
48798-3 First trimester maternal screen panel - Serum or Plasma
49086-2 First trimester maternal screen with nuchal translucency panel
55405-5 Heart failure tracking panel
75885-4 IEEE 11073 Rosetta panel
100203-9 Knee Society Score post-op panel [Knee Society Score]
100159-3 Knee Society Score pre-op panel [Knee Society Score]
89543-3 Laboratory ask at order entry panel
49087-0 Maternal screen clinical predictors panel
87825-6 National Trauma Data Standard - version 2018 set
98133-2 Osteoporosis Index of Risk panel
98139-9 Osteoporosis Risk Assessment Instrument
98146-4 Osteoporosis Self-Assessment Tool
93149-3 PhenX - bone age protocol 220301
62787-7 PhenX domain - Diabetes
62755-4 PhenX domain - Neurology
62812-3 PhenX domain - Physical activity and physical fitness
62710-9 PhenX domain - Psychiatric
62611-9 PhenX domain - Respiratory
63067-3 PhenX domain - Speech and hearing
48799-1 Second trimester penta maternal screen panel - Serum or Plasma
48800-7 Second trimester quad maternal screen panel - Serum or Plasma
35086-8 Second trimester triple maternal screen panel - Serum or Plasma
97782-7 Spine Tango Surgery 2017
81232-1 Supersaturation panel - 24 hour Urine
54127-6 US Surgeon General family health portrait [USSG-FHT]
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS
85353-1 Vital signs, weight, height, head circumference, oxygen saturation and BMI panel
55418-8 Weight and Height tracking panel

Member of these Groups Get Info

LOINC Group Group Name
LG34372-9 Body weight|Mass|Pt|^Patient

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Körpergewicht:Masse:Zeitpunkt:^Patient:Quantitativ:
de-AT German (Austria) Synonyms: Körpergewicht
es-AR Spanish (Argentina) peso corporal:masa:punto en el tiempo:^paciente:cuantitativo:
es-ES Spanish (Spain) Peso corporal:Masa:Punto temporal:^paciente:Qn:
Synonyms: Cuantitativo
es-MX Spanish (Mexico) Peso corporal:Masa:Punto temporal:^ Paciente:Cuantitativo:
fr-FR French (France) Poids corporel:Masse:Ponctuel:Patient:Numérique:
fr-BE French (Belgium) Poids corporel:Masse:Temps ponctuel:^Patient:Quantitatif:
Synonyms: Poids
fr-CA French (Canada) Poids corporel:Masse:Temps ponctuel:^Patient:Quantitatif:
it-IT Italian (Italy) Peso corporeo:Massa:Pt:^Paziente:Qn:
Synonyms: paziente Peso del corpo - atomico Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichaamsgewicht:massa:moment:^patiënt:kwantitatief:
pl-PL Polish (Poland) Masa ciała:masa:punkt w czasie:^pacjent:ilościowy:
Synonyms: Ciężar Masa ciała
pt-BR Portuguese (Brazil) Peso corpóreo:Massa:Pt:^Paciente:Qn:
Synonyms: ; Wt; Bdy weight; Point in time; Random; Quantitative; QNT; Quant; Quan; bod; Bodies; BODY WEIGHT.ATOM; BODY WEIGHT.ATOM
ru-RU Russian (Russian Federation) Масса тела:Масса:ТчкВрм:^Пациент:Колич:
Synonyms: Количественный Точка во времени;Момент
tr-TR Turkish (Turkey) Vücut ağırlığı:Kütle:Zmlı:^Hasta:Kant:
uk-UA Ukrainian (Ukraine) Вага тіла:Маса:МоментЧасу:^Пацієнт:Кількісно:
Synonyms: AOEObservation; Bdy weight; bod; Bodies; BODY WEIGHT.ATOM; Point in time; QNT; Quan; Quant; Quantitative; Random; Wt
zh-CN Chinese (China) 体重:质量:时间点:^患者:定量型:
Synonyms: 一般体重;一般身体重量;身体重量.原子型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 标本重量;重 物体 身体重量 重量

Example Units

Unit Source
[lb_av];kg Example UCUM Units
lb REGENSTRIEF

9269-2 Glasgow coma score total

Fully-Specified Name

Component
Glasgow coma score.total
Property
Fcn
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
GCS total

Basic Attributes

Class
FUNCTION
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73
Change Reason
We made an administrative decision to define the total scores from arious survey instruments as Quantitative rather than ordinal. There is no intention to change the existing meaning
Common Test Rank Get Info
1036

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
35088-4 Glasgow coma scale
75885-4 IEEE 11073 Rosetta panel
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set
96789-3 Sequential Organ Failure Assessment SOFA

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) puntuación de la escala de coma de Glasgow.total:función:punto en el tiempo:^paciente:ordinal:
es-MX Spanish (Mexico) Puntaje de coma de Glasgow total:Fcn:Punto temporal:^ Paciente:Cuantitativo:
it-IT Italian (Italy) Punteggio del coma di Glasgow.totale:Fcn:Pt:^Paziente:Qn:
Synonyms: Funzione paziente Punteggio totale del coma di Glasgow Punto nel tempo (episodio) Status funzionale (es., Glasgow)
ru-RU Russian (Russian Federation) Glasgow кома шкала.итог:Функц:ТчкВрм:^Пациент:Колич:
Synonyms: Итог Количественный Точка во времени;Момент Функция
zh-CN Chinese (China) 格拉斯哥昏迷评分.总计:功能:时间点:^患者:定量型:
Synonyms: FCN GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.总和;格拉斯哥昏迷得分.总分;格拉斯哥昏迷分值.总计 体格功能;体格检查功能;功能;躯体功能;身体功能 全体数量 全部 共计 分值;分数;得分 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 总 总和 总数 总量 总额 时刻;随机;随意;瞬间 汇总

Example Units

Unit Source
{score} Example UCUM Units

9267-6 Glasgow coma score eye opening

Fully-Specified Name

Component
Glasgow coma score.eye opening
Property
Fcn
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
GCS eye

Basic Attributes

Class
FUNCTION
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73
Common Test Rank Get Info
2970

Normative Answer List LL355-9

Answer Code Score Answer ID
No eye opening 1 1 LA6553-7
Eye opening to pain 2 2 LA6554-5
Eye opening to verbal command 3 3 LA6555-2
Eyes open spontaneously 4 4 LA6556-0

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
35088-4 Glasgow coma scale
75885-4 IEEE 11073 Rosetta panel
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) puntuación de la escala de coma de Glasgow.apertura ocular:función:punto en el tiempo:^paciente:ordinal:
es-MX Spanish (Mexico) Puntaje de coma de Glasgow. Apertura de ojos:Fcn:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Punteggio del coma di Glasgow.apertura occhi:Fcn:Pt:^Paziente:Ord:
Synonyms: Apertura occhi in punteggio del coma di Glasgow Funzione Occhio in punteggio del coma di Glasgow paziente Punto nel tempo (episodio) Status funzionale (es., Glasgow)
ru-RU Russian (Russian Federation) Glasgow кома шкала.глаза открывание:Функц:ТчкВрм:^Пациент:Пор:
Synonyms: Итог Порядковый Точка во времени;Момент Функция
zh-CN Chinese (China) 格拉斯哥昏迷分值.睁眼:功能:时间点:^患者:序数型:
Synonyms: FCN GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.眼睛;格拉斯哥昏迷得分.眼睛;格拉斯哥昏迷评分.眼睛 GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.睁眼;格拉斯哥昏迷得分.睁眼;格拉斯哥昏迷评分.睁眼 体格功能;体格检查功能;功能;躯体功能;身体功能 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 分值;分数;得分 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 时刻;随机;随意;瞬间 目;眼;眼部

9270-0 Glasgow coma score verbal

Fully-Specified Name

Component
Glasgow coma score.verbal
Property
Fcn
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
GCS verbal

Basic Attributes

Class
FUNCTION
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.27

Normative Answer List LL356-7

Answer Code Score Answer ID
No verbal response (>2 yrs); no vocal response (<=2 yrs) 1 1 LA6557-8
Incomprehensible sounds 2 2 LA6558-6
Inappropriate words 3 3 LA6559-4
Confused 4 4 LA6560-2
Oriented 5 5 LA6561-0

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
35088-4 Glasgow coma scale
75885-4 IEEE 11073 Rosetta panel
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) puntuación de la escala de coma de Glasgow.respuesta verbal:función:punto en el tiempo:^paciente:ordinal:
es-MX Spanish (Mexico) Puntuación de coma de Glasgow verbal:Fcn:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Punteggio del coma di Glasgow.verbale:Fcn:Pt:^Paziente:Ord:
Synonyms: Funzione paziente Punteggio verbale del coma di Glasgow Punto nel tempo (episodio) Status funzionale (es., Glasgow)
ru-RU Russian (Russian Federation) Glasgow кома шкала.вербалика:Функц:ТчкВрм:^Пациент:Пор:
Synonyms: Итог Порядковый Точка во времени;Момент Функция
zh-CN Chinese (China) 格拉斯哥昏迷分值.言语:功能:时间点:^患者:序数型:
Synonyms: FCN GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.言语;格拉斯哥昏迷得分.言语;格拉斯哥昏迷评分.言语;格拉斯哥昏迷分值.语言 体格功能;体格检查功能;功能;躯体功能;身体功能 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 分值;分数;得分 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 时刻;随机;随意;瞬间

9268-4 Glasgow coma score motor

Fully-Specified Name

Component
Glasgow coma score.motor
Property
Fcn
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
GCS motor

Basic Attributes

Class
FUNCTION
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73
Common Test Rank Get Info
2971

Normative Answer List LL357-5

Answer Code Score Answer ID
No motor response 1 1 LA6562-8
Extension to pain 2 2 LA6563-6
Flexion to pain 3 3 LA6564-4
Withdrawal from pain 4 4 LA6565-1
Localizing pain 5 5 LA6566-9
Obeys commands 6 6 LA6567-7

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
35088-4 Glasgow coma scale
75885-4 IEEE 11073 Rosetta panel
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) puntuación de la escala de coma de Glasgow.respuesta motriz:función:punto en el tiempo:^paciente:ordinal:
es-MX Spanish (Mexico) Puntuación de coma de Glasgow motor:Fcn:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Punteggio del coma di Glasgow.motorio:Fcn:Pt:^Paziente:Ord:
Synonyms: Funzione paziente Punteggio motorio del coma di Glasgow Punto nel tempo (episodio) Status funzionale (es., Glasgow)
ru-RU Russian (Russian Federation) Glasgow кома шкала.моторика:Функц:ТчкВрм:^Пациент:Пор:
Synonyms: Итог Порядковый Точка во времени;Момент Функция
zh-CN Chinese (China) 格拉斯哥昏迷分值.运动:功能:时间点:^患者:序数型:
Synonyms: FCN GCS;格拉斯哥昏迷分值;Glasgow coma score;格拉斯哥昏迷分数.运动;格拉斯哥昏迷得分.运动;格拉斯哥昏迷评分.运动 体格功能;体格检查功能;功能;躯体功能;身体功能 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 分值;分数;得分 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 时刻;随机;随意;瞬间

10199-8 Physical findings of Head Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Head
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Head

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Cabeza:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:cabeza:Narrativo:observado
fr-BE French (Belgium) Examen physique:Observation:Temps ponctuel:Tête:Narratif:Observé
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Testa:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:hoofd:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Crânio:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Skull; Brain; Intracranial; Cranium; Cranial; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Голова:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:头部:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 大脑;头;头壳;头的;头盖;头盖的;头盖骨;头部的;头颅;头颅内;头颅内的;头骨;脑;脑壳;脑的;颅;颅侧;颅的;颅骨;颅骨内;颅骨内的 时刻;随机;随意;瞬间 病史与体格检查 观测法

11411-6 Physical findings of Neck Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Neck
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Neck

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Cuello:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:cuello:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Collo:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:hals:tekstueel:observatie
Synonyms: nek
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Pescoço:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Шея:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:颈部:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 观测法 颈

11391-0 Physical findings of Chest Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Chest
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Chest

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Pecho:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:tórax:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Torace:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Petto Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:thorax:tekstueel:observatie
Synonyms: borst
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Tórax:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Thorax; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Грудная клетка:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:胸部:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 胸;胸廓;胸膛 观测法

11392-8 Physical findings of Chest wall Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Chest wall
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Chest wall

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Pared del pecho:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:pared torácica:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Parete toracica:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Petto Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:thoraxwand:tekstueel:observatie
Synonyms: borst borstwand
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Parede torácica:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Thorax; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Грудная стенка:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:胸壁:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 胸;胸廓;胸膛 观测法

10193-1 Physical findings of Breasts Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Breasts
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Brsts

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Pechos:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:mamas:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Mammelle:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio) Seni
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Mamas:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Brsts; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Молочные железы:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:乳腺类:叙述型:观察法
Synonyms: 乳腺(复数);乳房;乳房(复数);乳腺;乳腺(乳房) 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 观测法

11387-8 Physical findings of Axilla Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Axilla
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Axilla

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Axila:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:axila:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Ascella:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Axila:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Подмышечная ямка:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:腋窝:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 腋;腋下;胳肢窝;夹肢窝 观测法

10200-4 Physical findings of Heart Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Heart
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Hrt

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Corazón:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:corazón:Narrativo:observado
fr-BE French (Belgium) Examen physique:Observation:Temps ponctuel:Coeur:Narratif:Observé
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Cuore:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Coração:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Hrt; Cardiac; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Сердце:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:心脏:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 心 时刻;随机;随意;瞬间 病史与体格检查 观测法

10207-9 Physical findings of Thorax and Lungs Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Thorax+Lungs
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Thorax+Lungs

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Tórax + Pulmones:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:tórax+pulmones:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Torace+Polmoni:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio) Torace e Polmoni
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Torax+Pulmões:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Thoracic; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Грудная клетка+Лёгкие:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:胸腔+肺类:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 胸;胸廓;胸部 胸腔+肺类(肺、肺脏、肺部);胸腔+肺部;胸+肺;胸与肺;胸腔与肺部 观测法

10191-5 Physical findings of Abdomen Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Abdomen
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Abd

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Abdomen:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:abdomen:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Addome:Nar:Osservato
Synonyms: Addome e Esame obbiettivo Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:abdomen:tekstueel:observatie
Synonyms: buik
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Acdomen:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Acd; Acdominal; Acdo; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Живот:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:腹部:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 腹;肚子 腹部(腹、肚子)+;腹部与 观测法

11403-3 Physical findings of Groin Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Groin
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Groin

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Ingle:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:ingle:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Inguine:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Virilha:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Пах:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:腹股沟:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 观测法

10204-6 Physical findings of Pelvis Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Pelvis
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Pelvis

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Pelvis:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:pelvis:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Pelvi:Nar:Osservato
Synonyms: Bacino Esame obbiettivo Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:bekken:tekstueel:observatie
Synonyms: pelvis
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Pelve:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Pelvic; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Таз:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:盆腔:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 时刻;随机;随意;瞬间 病史与体格检查 盆腔(骨盆)+ 观测法 骨盆

11400-9 Physical findings of Genitalia Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Genitalia
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Genitalia

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Genitales:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:genitales:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Organi genitali:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Genitália:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Гениталии:Опис:Наблюдённый
Synonyms: Описательный Половые органы Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:生殖器:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 外生殖器;外阴部;生殖器(尤指外阴部);生殖器官 时刻;随机;随意;瞬间 病史与体格检查 观测法

11402-5 Physical findings of Male genitalia Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Genitalia.male
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Male genitalia

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Genitalia.male:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:genitales.masculinos:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Organi genitali.maschili:Nar:Osservato
Synonyms: Esame obbiettivo Organi genitali maschili Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Genitália.homem:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Male genitalia; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Гениталии.мужские:Опис:Наблюдённый
Synonyms: Мужские половые органы Описательный Половые органы Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:生殖器.男性:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 外生殖器.男性;外生殖器.雄性;外阴部.男性;外阴部.雄性;生殖器(尤指外阴部).男性;生殖器(尤指外阴部).雄性;生殖器.雄性;生殖器官.男性;生殖器官.雄性;男性外阴部;男性生殖器;雄性外阴部;雄性生殖器 外生殖器;外阴部;生殖器(尤指外阴部);生殖器官 时刻;随机;随意;瞬间 病史与体格检查 观测法

11401-7 Physical findings of Female genitalia Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Genitalia.female
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Female genitalia

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Genitalia.female:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:genitales.femeninos:Narrativo:observado
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Organi genitali.femminili:Nar:Osservato
Synonyms: Esame obbiettivo Organi genitali femminili Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Genitália.mulher:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Female genitalia; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Гениталии.женские:Опис:Наблюдённый
Synonyms: Женские половые органы Описательный Половые органы Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:生殖器.女性:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 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 外生殖器.女性;外生殖器.雌性;外阴部.女性;外阴部.雌性;女性外阴部;女性生殖器;生殖器(尤指外阴部).女性;生殖器(尤指外阴部).雌性;生殖器.雌性;生殖器官.女性;生殖器官.雌性;雌性外阴部;雌性生殖器 外生殖器;外阴部;生殖器(尤指外阴部);生殖器官 时刻;随机;随意;瞬间 病史与体格检查 观测法

11388-6 Physical findings of Buttocks Narrative

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
Buttocks
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find Buttocks

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico)