Version 2.77

Term Description

A labor and delivery admission history and physical (LDHP) document represents the patient's history and physical performed during admission to the birthing facility.
Source: Regenstrief LOINC

Reference Information

Type Source Reference
Webcontent Integrating the Healthcare EnterpriseCopyright Copyright © 2009 IHE International.

Fully-Specified Name

Component
Labor and delivery admission history and physical note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
L&D admin H&P note

Associated Observations

72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

This panel contains the recommended sections for history and physical notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
Indent48765-2 Alerts R
Indent51848-0 Assessment R
Indent51847-2 Assessment+Plan R
Indent10154-3 Chief complaint R
Indent10157-6 Family history R
Indent10210-3 General status R
Indent10164-2 History of present illness O
Indent11369-6 History of immunizations O
Indent69730-0 Instructions O
Indent10160-0 Medications R
Indent11348-0 Past medical history R
Indent29545-1 Physical examination R
Indent18776-5 Plan of care R
Indent11450-4 Problems O
Indent47519-4 Procedures O
Indent29299-5 Reason for visit R
Indent46239-0 Reason for visit and Chief complaint R
Indent30954-2 Results (Diagnostic findings) R
Indent10187-3 Review of systems R
Indent29762-2 Social history R
Indent8716-3 Vital signs R

81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections

This panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).

LOINC Name R/O/C Cardinality Example UCUM Units
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
Indent77599-9 Additional documentation R
Indent77598-1 Externally defined clinical data elements Document R
Indent47420-5 Functional status assessment note R
Indent77597-3 Orders placed Document R
Indent18776-5 Plan of care note R
Indent29762-2 Social history Narrative R
Indent77596-5 Transportation summary Document R
Indent42348-3 Advance directives O
Indent48765-2 Allergies R
Indent51847-2 Evaluation + Plan note R
Indent51848-0 Evaluation note R
Indent46239-0 Chief complaint+Reason for visit Narrative R
Indent10154-3 Chief complaint Narrative - Reported R
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative R
Indent10157-6 History of family member diseases Narrative R
Indent10210-3 Physical findings of General status Narrative R
Indent61146-7 Goals Narrative R
Indent75310-3 Health concerns Document R
Indent11383-7 Patient problem outcome Narrative R
Indent11348-0 History of Past illness Narrative R
Indent10164-2 History of Present illness Narrative R
Indent11369-6 History of Immunization Narrative R
Indent69730-0 Instructions R
Indent62387-6 Interventions Narrative R
Indent46264-8 History of medical device use R
Indent10160-0 History of Medication use Narrative R
Indent10190-7 Mental status Narrative R
Indent61144-2 Diet and nutrition Narrative R
Indent61149-1 Objective Narrative R
Indent48768-6 Payment sources Document R
Indent29545-1 Physical findings Narrative R
Indent11450-4 Problem list - Reported R
Indent47519-4 History of Procedures Document R
Indent42349-1 Reason for referral (narrative) R
Indent29299-5 Reason for visit Narrative R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent10187-3 Review of systems Narrative - Reported R
Indent61150-9 Subjective Narrative R
Indent8716-3 Vital signs R

92575-0 Labor and delivery admission history and physical - recommended IHE set

The recommended set of terms to be used within a Labor and delivery admission history and physical note [LOINC: 57056-4] based on the IHE Labor and Delivery Admission History and Physical (LDHP) profile. The LDHP represents the patient's history and physical performed during admission to the birthing facility.

LOINC Name R/O/C Cardinality Example UCUM Units
92575-0 Labor and delivery admission history and physical - recommended IHE set
Indent10154-3 Chief complaint
Indent10164-2 History of present illness
Indent11348-0 History of past illness
Indent56838-6 History of infection
Indent10162-6 Pregnancy history
Indent29762-2 Social history
Indent10157-6 Coded family medical history
Indent10187-3 Review of systems
Indent29545-1 Physical exam
Indent8716-3 Vital signs

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.67
Change Reason
Previous Releases: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

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

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Historial de admisión de trabajo de parto y parto y nota física:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Travaglio e parto, anamnesi e visita medica:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Anamnesi e visita medica in travaglio e parto Documentazione dell''ontologia Erogazione prescrizione di ricovero: accettazione; Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) voorgeschiedenis en lichamelijke conditie bij opname zwangerschap en geboorte:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 临产和分娩入院病史与体格检查记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临产(阵痛)和分娩入院病史与体格检查记录;阵痛和分娩入院病史与体格检查记录;分娩入院病史与体格检查记录;临产和分娩入院史与体格检查记录;临产和分娩入院历史与体格检查记录;临产和分娩住院病史与体格检查记录 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=57056-4