Version 2.80

57055-6 Antepartum summary note

Term Description

The Antepartum Summary represents a summary of the most critical information to an antepartum care provider regarding the status of a patients pregnancy. The APS document is a medical summary and inherits all header constraints from Medical Summaries.

Reference Information

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

Fully-Specified Name

Component
Antepartum summary note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Basic Attributes

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

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Member of these Groups Get Info

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

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Συνοπτικό σημείωμα πριν τον τοκετό:Εύρεση:Pt:{Ρυθμίσεις}:Doc:{Ρόλος}
Synonyms: Εύρεση Περίληψη σημειώματος Σημείωση Συνοπτικό σημείωμα πριν τον τοκετό
es-MX Spanish (Mexico) Nota resumida anteparto:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Prospetto antepartum:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di sintesi anteparto Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) anteparum samenvatting:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 分娩前摘要记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 分娩前（产前）摘要（小结、概要、总结、梗概、概括、总汇）记录;分娩前小结记录;产前摘要记录;产前小结记录 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 小结;概要;概括;总汇;总结 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

48765-2 Allergies and adverse reactions Document

Term Description

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

Fully-Specified Name

Component
Allergies &or adverse reactions
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.21
Last Updated
Version 2.73 (MIN)
Change Reason
Previous Releases: Edited Component part from "Allergies, adverse reactions, alerts" to "Allergies &or adverse reactions." We removed the word "alerts" because it was potentially confusing by implying that it may contain other kinds of warnings (as a arbitrary example: public health disease outbreak notifications) when in fact it was always intended to be the typical "allergies" section.;
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record 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
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
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
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
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
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
de-DE German (Germany) Allergien und unerwünschte Wirkungen:Befund:Zeitpunkt:^Patient:Dokument:
el-GR Greek (Greece) Αλλεργίες και/ή ανεπιθύμητες ενέργειες:Εύρεση:Pt:^Ασθενής:Doc:
Synonyms: Αλλεργίες Αλλεργίες και/ή ανεπιθύμητες ενέργειες Εύρεση
es-MX Spanish (Mexico) Alergias y reacciones adversas:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Allergie &o reazioni avverse:Osservazione:Pt:^Paziente:Doc:
Synonyms: Allergie e reazioni avverse Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) allergieën en/of allergische reacties:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Аллергии &или неблагоприятные реакции:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 变态反应和或不良反应:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 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 变态反应与不良反应 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 过敏反应;过敏

42348-3 Advance healthcare directives

Term Description

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

Fully-Specified Name

Component
Advance healthcare directives
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.16
Last Updated
Version 2.79 (NAM)
Change Reason
Release 2.79: COMPONENT: Adding the descriptor "healthcare" better reflects its intended use in healthcare contexts, updating the term to "Advance healthcare directives." This modification aims to encompass a broader range of healthcare-specific advance directives; Previous Releases: Based on Clinical LOINC Committee review at the Feb. 2016 meeting, this term represents a document containing information on a patient's advance directives and any supporting documentation, such as a living will. The term was revised to fit the current LOINC Document Ontology model.;
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel
69459-6 Care record summary panel
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
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
71531-8 ESRD hospitalization panel
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
82811-1 Nurse summary note - recommended sections
74449-0 Patient plan of care - recommended IHE set
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

Member of these Groups Get Info

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

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Patientenverfügung:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-MX Spanish (Mexico) Directivas avanzadas:Tipo:Punto temporal:{Configuración}:Documento:{Role}
fr-CA French (Canada) Directives médicales anticipée:Observation:Temps ponctuel:{Situation}:Document:{Rôle}
it-IT Italian (Italy) Direttive sanitarie anticipate:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Direttive sanitarie anticipate Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) wilsverklaring:bevinding:moment:{instelling}:document:{rol}
pt-BR Portuguese (Brazil) Diretivas avançadas:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
zh-CN Chinese (China) 健康医疗服务事前指示类:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 健康医疗服务（医疗服务、医疗）事前指示（遗嘱、事前意愿、遗愿、事前要求）类;健康医疗服务事前指示;健康医疗服务事前意愿;健康医疗服务事前要求;健康医疗服务遗嘱;健康医疗服务遗愿 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

18776-5 Plan of care note

Term Description

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

Fully-Specified Name

Component
Plan of care note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 1.0l
Last Updated
Version 2.67 (MIN)
Change Reason
Previous Releases: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.;
Order vs. Observation
Both
HL7® Attachment Structure
IG exists

Member of these Panels

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
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
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
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
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
72227-2 Surgical operation note - recommended C-CDA R1.1 and 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

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38745-2 Plan of care note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Behandlungsplan - Notiz:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
el-GR Greek (Greece) Σημείωμα σχεδίου φροντίδας:Εύρεση:Pt:{Ρυθμίσεις}:Doc:{Ρόλος}
Synonyms: Εύρεση
es-AR Spanish (Argentina) plan de tratamiento:hallazgo:punto en el tiempo:plan de tratamiento:Narrativo:
es-MX Spanish (Mexico) Nota del plan de cuidados:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) behandelplan:bevinding:moment:{instelling}:document:{rol}
Synonyms: zorgplan
zh-CN Chinese (China) 医疗服务计划记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 医疗服务（照护服务、护理服务、护理、照护、医疗照护、诊疗、诊疗服务、照顾、看护）计划（方案）记录 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

11450-4 Problem list - Reported

Fully-Specified Name

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

Basic Attributes

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

Member of these Panels

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
el-GR Greek (Greece) Κατάλογος προβλημάτων:Εύρεση:Pt:^Ασθενής:Nom:Αναφερόμενη
Synonyms: Εύρεση
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-CA French (Canada) Liste des problèmes:Observation:Temps ponctuel:^Patient:Nominal:Rapporté
fr-BE French (Belgium) Liste de 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

18610-6 Medication administered Set

Fully-Specified Name

Component
Medication.administered
Property
Cmplx
Time
Pt
System
^Patient
Scale
Set
Method

Basic Attributes

Class
ATTACH.MEDS
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel
81898-9 Composite triage and nursing note - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82811-1 Nurse summary note - recommended sections
74449-0 Patient plan of care - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Φαρμακευτική αγωγή.χορηγηθείσα:Cmplx:Pt:^Ασθενής:Set:
Synonyms: Cmplx
es-AR Spanish (Argentina) medicación.administrada:complejo:punto en el tiempo:^paciente:Conjunto:
fr-FR French (France) Traitement administré:Autre:Ponctuel:Patient:Statut:
it-IT Italian (Italy) Farmaco.somminstrato:Cmplx:Pt:^Paziente:Determinato:
Synonyms: Allegato Allegato farmaci Complesso paziente Punto nel tempo (episodio) Stabilito;Fissato
nl-NL Dutch (Netherlands) toegediende medicatie:complex:moment:^patiënt:set:
Synonyms: geneesmiddelen
ru-RU Russian (Russian Federation) Лекарственный препарат.введённый:Кмплкс:ТчкВрм:^Пациент:Множество:
Synonyms: Комплекс Лекарство введено Точка во времени;Момент
zh-CN Chinese (China) 药物.已施用的:复合型属性:时间点:^患者:集合型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.药物处理;健康保险便携与责任法案信息附件.药物处理;健康保险便携与责任法案信息附件.药物治疗;药物处理HIPAA信息附件;药物处理信息附件;药物处理健康保险便携与责任法案信息附件 临床信息附件集;临床信息附件集合;集;集合 信息附件;健康保险便携与责任法案信息附件;附件 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 处理用药.已施用的;处理用药.已服用的;处理用药.已给予的;处理用药物.已施用的;处理用药物.已服用的;处理用药物.已给予的;处理药物.已施用的;处理药物.已服用的;处理药物.已给予的;已施用的处理药物;已施用的治疗药物;已服用的处理药物;已服用的治疗药物;已给予的处理药物;已给予的治疗药物;治疗用药.已施用的;治疗用药.已服用的;治疗用药.已给予的;治疗用药物.已施用的;治疗用药物.已服用的;治疗用药物.已给予的;治疗药物.已服用的;治疗药物.已给予的;治疗药物.已施用的;治疗药物.已服用的;治疗药物. 处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 复合属性;复杂型属性;复杂属性 所施用的药物;已使用的药物;已使用的处理用药;已使用的处理用药物;已使用的处理药物;已使用的治疗用药;已使用的治疗用药物;已使用的用药;已使用的药物处理;已使用的药物治疗;已使用的治疗药物 时刻;随机;随意;瞬间 药物;药物处理;用药;使用药物

57059-8 Pregnancy visit summary note Narrative

Term Description

This section is a running history of the most important elements noted for a pregnant woman.

Reference Information

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

Fully-Specified Name

Component
Pregnancy visit summary note
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Συνοπτικό σημείωμα επίσκεψης εγκυμοσύνης:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Κύηση Περίληψη σημειώματος Σημείωση Συνοπτικό σημείωμα επίσκεψης εγκυμοσύνης
es-MX Spanish (Mexico) Nota de resumen de la visita de embarazo:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Gravidanza, nota di sintesi visita:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Nota di sintesi visita gravidanza Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) samenvatting zwangerschapbezoek:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Беременность визит краткие сведения запись:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 妊娠就诊摘要: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 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 妊娠就诊小结;妊娠就医摘要;妊娠访视摘要 小结;概要;概括;总汇;总结 怀孕;怀孕期;妊娠期 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 笔记;按语;注释;说明;票据;单据;证明书

57066-3 Date fundal height reaches umbilicus

Fully-Specified Name

Component
Date fundal height reaches umbilicus
Property
Date
Time
Pt
System
^Patient
Scale
Qn
Method

Basic Attributes

Class
OB.US
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.50 (MAJ)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Ημερομηνία που το ύψος του πυθμένα της μήτρας φτάνει στον ομφαλό:Ημερομηνία:Pt:^Ασθενής:Qn:
Synonyms: Ημερομηνία Ημερομηνία που το ύψος του πυθμένα της μήτρας φτάνει στον ομφαλό Ύψος Ύψος πυθμένα
es-MX Spanish (Mexico) Fecha en que la altura del fondo uterino alcanza el ombligo:Fecha:Punto temporal:^ Paciente:Cuantitativo:
it-IT Italian (Italy) Data altezza fundal raggiunge ombelico:Data:Pt:^Paziente:Qn:
Synonyms: Ecografia ostetrica paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Data em que a altura uterina alcança umbigo:#N/A:Pt:^Paciente:Qn:
Synonyms: Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan; OBSTERICAL.ULTRASOUND; OBSTERICAL.ULTRASOUND; Obstetrical; Obstetrics
ru-RU Russian (Russian Federation) Дата дно матки высота достигает пупок:Дата:ТчкВрм:^Пациент:Колич:
Synonyms: Высота дна Количественный Точка во времени;Момент
zh-CN Chinese (China) 宫高达到脐部日期:日期:时间点:^患者:定量型:
Synonyms: 产科 产科.超声;产科.超声.印象与测量指标;产科学.超声;产科学.超声.印象与测量指标;产科学检查与测量指标.超声.印象与测量指标;产科学超声印象与测量指标 产科学 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 宫高达脐日期;宫高至脐日期;宫高达到脐部高度的日期 日子;几号 时刻;随机;随意;瞬间 身高;身长;身体高度

57061-4 Antepartum flowsheet panel Narrative

Term Description

This entry describes a single row in the Visit Summary flowsheet. The single observation date and provider is applied to all other observations. The battery is made of several component simple observations for a single visit which make up a battery.

Fully-Specified Name

Component
Antepartum flowsheet panel
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.50 (MIN)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Πίνακας φύλλου καταγραφής πριν τον τοκετό:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Πίνακας φύλλου καταγραφής πριν τον τοκετό Φύλλο καταγραφής
es-MX Spanish (Mexico) Panel de diagrama de flujo anteparto:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Diagramma antepartum, panel:Osservazione:Pt:^Paziente:Nar:
Synonyms: Clinico Osservazione Panel diagramma anteparto paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Painel do fluxograma do anteparto:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report; Pnl; Pan; Panl
ru-RU Russian (Russian Federation) Дородовая технологическая карта панель:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Панель дородовая карта наблюдения Точка во времени;Момент
zh-CN Chinese (China) 分娩前流程记录单组套:发现:时间点:^患者:叙述型:
Synonyms: 分娩前流程记录单（流程图、作业流程、操作流程、工作流程、作业图、工艺流程图、流向图、程序框图、操作程序图、记录、记录单、流程记录、流程、作业记录、作业记录单）组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目）;分娩前流程记录单组套;分娩前流程记录单组合;分娩前流程记录单医嘱组 医嘱套餐 医嘱组合 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 套餐 套餐医嘱 时刻;随机;随意;瞬间 流程图;作业流程;操作流程;工作流程;作业图;工艺流程图;流向图;程序框图;操作程序图;记录;记录单;流程记录;流程记录单;作业记录;作业记录单 组 组合 组合医嘱 组套

57067-1 Fetal Body weight Estimated by palpation

Fully-Specified Name

Component
Body weight
Property
Mass
Time
Pt
System
^Fetus
Scale
Qn
Method
Estimated by palpation

Basic Attributes

Class
OB.US
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.48 (MIN)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Member of these Groups Get Info

LOINC Group Group Name
LG50068-2 Body weight|Mass|^Fetus|ANYMethod

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σωματικό βάρος:Mass:Pt:^Έμβρυο:Qn:Εκτιμάται με ψηλάφηση
Synonyms: Mass Βάρος Σωματικό βάρος
es-MX Spanish (Mexico) Peso corporal:Masa:Punto temporal:^ Feto:Cuantitativo:Estimated by palpation
it-IT Italian (Italy) Peso corporeo:Massa:Pt:^feto:Qn:Stimato tramite palpazione
Synonyms: Ecografia ostetrica Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Peso corporal:#N/A:Pt:^Feto:Qn:Estimado pela palpação
Synonyms: ; Wt; Bdy weight; Point in time; Random; Fet; Fetal; Quantitative; QNT; Quant; Quan; Est by palpation; estimation; bod; Bodies; OBSTERICAL.ULTRASOUND; OBSTERICAL.ULTRASOUND; Obstetrical; Obstetrics; EFW; Estimated fetal weight
zh-CN Chinese (China) 体重:质量:时间点:^胎儿:定量型:触诊估计法
Synonyms: 产科 产科.超声;产科.超声.印象与测量指标;产科学.超声;产科学.超声.印象与测量指标;产科学检查与测量指标.超声.印象与测量指标;产科学超声印象与测量指标 产科学 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 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 扪诊估计法;通过触诊来估计的方法;切脉估计法;切诊估计法;按诊估计法;触摸估计法 时刻;随机;随意;瞬间 标本重量;重 物体 胎;超系统 - 胎儿 胎龄估计法;孕龄估计法 身体重量 重量

Example Units

Unit Source
g Example UCUM Units

57068-9 Fetal Heart rate by Auscultation

Fully-Specified Name

Component
Heart rate
Property
NRat
Time
Pt
System
^Fetus
Scale
Qn
Method
Auscultation

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.54 (MIN)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Καρδιακός ρυθμός:NRat:Pt:^Έμβρυο:Qn:Ακρόαση
Synonyms: NRat Αξία Καρδιακός ρυθμός
es-MX Spanish (Mexico) Ritmo cardiaco:NRat:Punto temporal:^ Feto:Cuantitativo:Auscultation
it-IT Italian (Italy) Frequenza cardiaca:NRat:Pt:^feto:Qn:Auscultazione
Synonyms: Anamnesi Indice numerico Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Frequência cardíaca:#N/A:Pt:^Feto:Qn:Auscultação
Synonyms: ; nRate; Number rate; Count/time; Point in time; Random; Fet; Fetal; Quantitative; QNT; Quant; Quan; Ausc; Pulse; Heart beat
zh-CN Chinese (China) 心率:计数型速率:时间点:^胎儿:定量型:听诊法
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) 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 听;听诊 心搏率;心跳速率 时刻;随机;随意;瞬间 病史与体格检查 胎;超系统 - 胎儿 速度

Example Units

Unit Source
{beats}/min Example UCUM Units

57065-5 Quickening date

Fully-Specified Name

Component
Quickening date
Property
Date
Time
Pt
System
^Patient
Scale
Qn
Method
Reported

Basic Attributes

Class
OB.US
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.50 (MAJ)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Ημερομηνία ζωοποίησης:Ημερομηνία:Pt:^Ασθενής:Qn:Αναφερόμενη
Synonyms: Ημερομηνία Ημερομηνία ζωοποίησης
es-MX Spanish (Mexico) Fecha de aceleración:Fecha:Punto temporal:^ Paciente:Cuantitativo:Reported
it-IT Italian (Italy) Prima percezione movimenti fetali, data:Data:Pt:^Paziente:Qn:Riportato
Synonyms: Data di prima percezione di movimenti fetali Ecografia ostetrica paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Data antecipada:#N/A:Pt:^Paciente:Qn:Relatado
Synonyms: Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan; OBSTERICAL.ULTRASOUND; OBSTERICAL.ULTRASOUND; Obstetrical; Obstetrics
ru-RU Russian (Russian Federation) Начало шевеление плод дата:Дата:ТчкВрм:^Пациент:Колич:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Дата начала шевеления плода Количественный Точка во времени;Момент
zh-CN Chinese (China) 胎动初感日期:日期:时间点:^患者:定量型:报告法
Synonyms: 产科 产科.超声;产科.超声.印象与测量指标;产科学.超声;产科学.超声.印象与测量指标;产科学检查与测量指标.超声.印象与测量指标;产科学超声印象与测量指标 产科学 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 日子;几号 时刻;随机;随意;瞬间 胎动感日期;胎动初觉日期;初觉胎动日期;胎动日期;胎动初始;胎动初期;速度加快日期;加速日期

57088-7 Fetal Movement - Reported

Fully-Specified Name

Component
Movement
Property
Find
Time
Pt
System
^Fetus
Scale
Ord
Method
Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.29 (MIN)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel
100230-2 Routine prenatal assessment panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Κίνηση:Εύρεση:Pt:^Έμβρυο:Ord:Αναφερόμενη
Synonyms: Εύρεση Κίνηση
es-MX Spanish (Mexico) Movimiento:Tipo:Punto temporal:^ Feto:Ordinal:Reported
es-ES Spanish (Spain) Movimiento:Hallazgo:Punto temporal:^Feto:Ord:Informado
it-IT Italian (Italy) Movimento:Osservazione:Pt:^feto:Ord:Riportato
Synonyms: Anamnesi Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Movimento:Achado:Pt:^Feto:Ord:Relatado
Synonyms: Finding; Findings; Point in time; Random; Fet; Fetal; Ql; Ordinal; QL; Qualitative; Qual; Screen
ru-RU Russian (Russian Federation) Движение:Находка:ТчкВрм:^Плод:Пор:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Порядковый Точка во времени;Момент
zh-CN Chinese (China) 运动:发现:时间点:^胎儿:序数型:报告法
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 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 活动;动作;举动;运行;移动 病史与体格检查 胎;超系统 - 胎儿

57064-8 Delivery date Estimated from date fundal height reaches umb

Fully-Specified Name

Component
Delivery date
Property
Date
Time
Pt
System
^Patient
Scale
Qn
Method
Estimated from date fundal height reaches umb

Basic Attributes

Class
OB.US
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.50 (MIN)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Member of these Groups Get Info

LOINC Group Group Name
LG50114-4 Delivery dateDate^Patient

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Entbindungstermin:Datum:Zeitpunkt:^Patient:Quantitativ:Geschätzt aus Fundusstand
el-GR Greek (Greece) Ημερομηνία τοκετού:Ημερομηνία:Pt:^Ασθενής:Qn:Εκτιμώμενο με βάση την ημερομηνία που το ύψος του πυθμένα της μήτρας φτάνει στον ομφαλό
Synonyms: Ημερομηνία Ημερομηνία τοκετού
es-MX Spanish (Mexico) Fecha de entrega:Fecha:Punto temporal:^ Paciente:Cuantitativo:Estimated from date fundal height reaches umb
it-IT Italian (Italy) Data del parto:Data:Pt:^Paziente:Qn:Stimato in base a data in cui altezza fundale raggiunge ombelico
Synonyms: Ecografia ostetrica paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Data provável do parto:#N/A:Pt:^Paciente:Qn:Estimado a partir da data de altura uterina alcançada
Synonyms: Due date; Date of confinement; Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan; Est from date fundal height reaches umb; predicted; estimation; OBSTERICAL.ULTRASOUND; OBSTERICAL.ULTRASOUND; Obstetrical; Obstetrics; EDC; EDD
zh-CN Chinese (China) 分娩日期:日期:时间点:^患者:定量型:依据宫高达到脐部日期的估计法
Synonyms: EDD Estimated delivery date 交货日期;交货期;落货期;投送日期 产科 产科.超声;产科.超声.印象与测量指标;产科学.超声;产科学.超声.印象与测量指标;产科学检查与测量指标.超声.印象与测量指标;产科学超声印象与测量指标 产科学 估计的分娩日期 依据宫高达脐日期的估计法;依据宫高至脐日期的估计法;依据宫高达到脐部高度的日期的估计法 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 日子;几号 时刻;随机;随意;瞬间 胎龄估计法;孕龄估计法 预估的分娩日期 预计的分娩日期

57069-7 Preterm labor symptoms

Fully-Specified Name

Component
Preterm labor symptoms
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.73 (MIN)
Common Test Rank Get Info
7098

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Συμπτώματα πρόωρου τοκετού:Εύρεση:Pt:^Ασθενής:Nom:
Synonyms: Εύρεση Συμπτώματα πρόωρου τοκετού
es-MX Spanish (Mexico) Síntomas de trabajo de parto prematuro:Tipo:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Doglie pretermine, sintomi:Osservazione:Pt:^Paziente:Nom:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) Sintomi di doglie pretermine
pt-BR Portuguese (Brazil) Sintomas prematuros de trabalho:Achado:Pt:^Paciente:Nom:
Synonyms: Finding; Findings; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Преждевременные роды симптомы:Находка:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 早产症状:发现: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 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 未足月产症状 病史与体格检查 症状类

57063-0 Delivery date Estimated from quickening date

Fully-Specified Name

Component
Delivery date
Property
Date
Time
Pt
System
^Patient
Scale
Qn
Method
Estimated from quickening date

Basic Attributes

Class
OB.US
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.50 (MIN)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Member of these Groups Get Info

LOINC Group Group Name
LG50114-4 Delivery dateDate^Patient

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Entbindungstermin:Datum:Zeitpunkt:^Patient:Quantitativ:Geschätzt aus ersten Kindsbewegungen
el-GR Greek (Greece) Ημερομηνία τοκετού:Ημερομηνία:Pt:^Ασθενής:Qn:Εκτιμώμενο με βάση την ημερομηνία ζωοποίησης
Synonyms: Ημερομηνία Ημερομηνία τοκετού
es-MX Spanish (Mexico) Fecha de entrega:Fecha:Punto temporal:^ Paciente:Cuantitativo:Estimated from quickening date
it-IT Italian (Italy) Data del parto:Data:Pt:^Paziente:Qn:Stimato in base a data prima percezione movimenti fetali
Synonyms: Ecografia ostetrica paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Data provável do parto:#N/A:Pt:^Paciente:Qn:Estimado a partir da data estipulada
Synonyms: Due date; Date of confinement; Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan; Est from quickening date; predicted; estimation; OBSTERICAL.ULTRASOUND; OBSTERICAL.ULTRASOUND; Obstetrical; Obstetrics; EDC; EDD
zh-CN Chinese (China) 分娩日期:日期:时间点:^患者:定量型:依据胎动初感日期的估计法
Synonyms: EDD Estimated delivery date 交货日期;交货期;落货期;投送日期 产科 产科.超声;产科.超声.印象与测量指标;产科学.超声;产科学.超声.印象与测量指标;产科学检查与测量指标.超声.印象与测量指标;产科学超声印象与测量指标 产科学 估计的分娩日期 依据胎动初觉日期的估计法;依据初觉胎动日期的估计法;依据胎动日期的估计法;依据胎动初始的估计法;依据胎动初期的估计法 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 日子;几号 时刻;随机;随意;瞬间 胎龄估计法;孕龄估计法 预估的分娩日期 预计的分娩日期

57070-5 Date next clinic visit

Fully-Specified Name

Component
Date next clinic visit
Property
Date
Time
Pt
System
^Patient
Scale
Qn
Method

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.50 (MIN)

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Ημερομηνία επόμενης επίσκεψης στην κλινική:Ημερομηνία:Pt:^Ασθενής:Qn:
Synonyms: Ημερομηνία Ημερομηνία επόμενης επίσκεψης στην κλινική
es-MX Spanish (Mexico) Fecha de la próxima visita a la clínica:Fecha:Punto temporal:^ Paciente:Cuantitativo:
it-IT Italian (Italy) Data prossima visita clinica:Data:Pt:^Paziente:Qn:
Synonyms: Anamnesi paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Data da próxima visita clínica:#N/A:Pt:^Paciente:Qn:
Synonyms: Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Дата следующий клиника визит:Дата:ТчкВрм:^Пациент:Колич:
Synonyms: Количественный Точка во времени;Момент
zh-CN Chinese (China) 下次门诊就诊日期:日期:时间点:^患者:定量型:
Synonyms: 下次门诊就医日期 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 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 时刻;随机;随意;瞬间 病史与体格检查

57060-6 Estimated date of delivery Narrative

Reference Information

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

Fully-Specified Name

Component
Estimated date of delivery
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.73 (MIN)
Common Test Rank Get Info
17949

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Εκτιμώμενη ημερομηνία τοκετού:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εκτιμώμενη ημερομηνία τοκετού Εύρεση
es-MX Spanish (Mexico) Fecha estimada de entrega:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Data stimata del parto:Osservazione:Pt:^Paziente:Nar:
Synonyms: Clinico Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) à terme datum:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Data estimada para o parto:Achado:Pt:^Paciente:Nar:
Synonyms: ; Est date of delivery; Finding; Findings; Point in time; Random; Narrative; Report; EDC; EDD
ru-RU Russian (Russian Federation) Предполагаемая дата родоразрешения:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Предполагаемая дата родов Точка во времени;Момент
zh-CN Chinese (China) 预产期:发现:时间点:^患者:叙述型:
Synonyms: EDD Estimated delivery date 估计交货期;估计交货日期;EDD;expected date of delivery;EDC;expected date of confinement;估计分娩日期 估计的分娩日期 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 日子;几号 时刻;随机;随意;瞬间 预估的分娩日期 预计的分娩日期