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

Term Description

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.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Labor and delivery admission history and physical - recommended IHE set

Property

-

Time

Pt

System

{Setting}

Scale

-

Method

Additional Names

Short Name

LDHP - recommended IHE set

Basic Attributes

Class

PANEL.DOC

Type

Clinical

First Released

Version 2.66

Last Updated

Version 2.66

Panel Type

Convenience group

Member of these Panels

Language Variants Get Info

Related Names

• Hx
• LDHP - recommended IHE set
• Pan
• Panel
• PANEL.DOC
• Panl
• Pnl
• Point in time
• Random

10154-3 Chief complaint

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

Language Variants Get Info

Related Names

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

10164-2 History of present illness

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

Language Variants Get Info

Related Names

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

11348-0 History of past illness

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

Language Variants Get Info

Related Names

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

56838-6 History of infection

Reference Information

Fully-Specified Name

Component

Infectious disease

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Infectious disease

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.63

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

10162-6 Pregnancy history

Fully-Specified Name

Component

History of pregnancies

Property

Hx

Time

Pt

System

Reproductive system

Scale

Nar

Method

Additional Names

Short Name

Pregnancies Hx

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Change Reason

Previous Releases: Changed Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• Gestation
• Gestations
• Gravida
• H/O
• H+P
• H+P.HX
• History
• Hx
• Narrative
• P prime
• Point in time
• Pregnancies Hx
• Pregnancy
• Random
• Report

29762-2 Social history

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

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Hx
• Narrative
• P prime
• Point in time
• Random
• Report
• Social Hx

10157-6 Coded family medical history

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

Language Variants Get Info

Related Names

• Fam Mem
• Family member diseases Hx
• H/O
• H+P
• H+P.HX
• History
• Hx
• Narrative
• P prime
• Point in time
• Random
• Report

10187-3 Review of systems

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

Language Variants Get Info

Related Names

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

29545-1 Physical exam

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

Language Variants Get Info

Related Names

• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• Narrative
• P prime
• Phys find
• Point in time
• Random
• Report

8716-3 Vital signs

Term Description

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

Fully-Specified Name

Component

Vital signs

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Observed

Additional Names

Short Name

Vital signs

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.73

Common Test Rank Get Info

576

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.PX
• Narrative
• P prime
• Point in time
• Random
• Report

92574-3 Labor and delivery summary - recommended IHE set

Term Description

The recommended set of terms to be used within a Labor and delivery summaryl note [LOINC: 57057-2] based on the IHE Labor and Delivery Admission History and Physical (LDHP) profile. The LDS represents a summary of the most critical information concerning the labor and delivery care in a birthing facility.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Labor and delivery summary - recommended IHE set

Property

-

Time

Pt

System

{Setting}

Scale

-

Method

Additional Names

Short Name

LDS - recommended IHE set

Basic Attributes

Class

PANEL.DOC

Type

Clinical

First Released

Version 2.66

Last Updated

Version 2.66

Panel Type

Convenience group

Member of these Panels

Language Variants Get Info

Related Names

• LDS - recommended IHE set
• Pan
• Panel
• PANEL.DOC
• Panl
• Pnl
• Point in time
• Random

46241-6 Hospital admission diagnosis

Fully-Specified Name

Component

Hospital admission Dx

Property

Imp

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Additional Names

Short Name

Hospital admission Dx Reported

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

Language Variants Get Info

Related Names

• Diagnosis
• H+P
• H+P.HX
• Hosp
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• Narrative
• P prime
• Point in time
• Random
• Report

Related Codes

10154-3 Chief complaint

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

Language Variants Get Info

Related Names

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

11459-5 Transport mode

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

Example Answer List LL483-9

Member of these Panels

Language Variants Get Info

Related Names

• DEEDS
• Emergency Department
• EMERGENCY DEPARTMENT (DEEDS)
• Emergency Medical Service(s)
• EMS
• NEMSIS
• Nominal
• Point in time
• Random
• Typ

10160-0 Admission medication history

Term Description

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

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Medication use

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

Language Variants Get Info

Related Names

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

51847-2 Assessment and plan

Term Description

The Assessment and Plan note (also called impression or diagnoses) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block. The Plan section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education was given or will be provided.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Evaluation+Plan note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Eval+Plan note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.63

Change Reason

Previous Releases: Changed 'Assesment' to 'Evaluation' to harmonize existing terms with similar meaning. The term 'Evaluation' will be used in the LOINC Document Ontoloy based on Clinical LOINC Committee decision (Sept 2014).; 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

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Assessment
• Assessment+Plan note
• DOC.ONT
• Document
• Encounter
• Eval
• Eval+Plan note
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H&P
• History and physical
• notes
• Point in time
• Random
• Visit note

30954-2 Coded results

Fully-Specified Name

Component

Relevant diagnostic tests &or laboratory data

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Relevant Dx tests/lab data

Basic Attributes

Class

VACCIN

Type

Clinical

First Released

Version 2.04

Last Updated

Version 2.63

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• Narrative
• Point in time
• Random
• Relevant Dx tests/lab data
• Report
• VACCINE

10164-2 History of present illness

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

Language Variants Get Info

Related Names

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

11348-0 History of past illness

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

Language Variants Get Info

Related Names

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

56838-6 Coded history of infection

Reference Information

Fully-Specified Name

Component

Infectious disease

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Infectious disease

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.63

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

42348-3 Coded advanced 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.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Advance directives

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Advance directives

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.16

Last Updated

Version 2.67

Change Reason

Previous Releases: Based on Clinical LOINC Committee review at the Feb. 2016 meeting, this term represents a document containing information on a patient's advance directives and any supporting documentation, such as a living will. The term was revised to fit the current LOINC Document Ontology model.;

Order vs. Observation

Both

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

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

57079-6 Birth plan

Term Description

The Birth Plan section shall contain a narrative description of the patient's requests and expectations with respect to care she is expecting during the labor and delivery process.
Source: Regenstrief LOINC

Reference Information

Fully-Specified Name

Component

Birth plan

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Birth plan

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.73

Common Test Rank Get Info

6251

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.PX
• Narrative
• P prime
• Point in time
• Random
• Report

48765-2 Allergies and other adverse reactions

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.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Additional Names

Short Name

Allergies &or adverse reactions Doc

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73

Change Reason

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

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

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

29545-1 Coded physical exam

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

Language Variants Get Info

Related Names

• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• Narrative
• P prime
• Phys find
• Point in time
• Random
• Report

10162-6 Pregnancy history

Fully-Specified Name

Component

History of pregnancies

Property

Hx

Time

Pt

System

Reproductive system

Scale

Nar

Method

Additional Names

Short Name

Pregnancies Hx

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Change Reason

Previous Releases: Changed Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• Gestation
• Gestations
• Gravida
• H/O
• H+P
• H+P.HX
• History
• Hx
• Narrative
• P prime
• Point in time
• Pregnancies Hx
• Pregnancy
• Random
• Report

57060-6 Estimated delivery dates

Reference Information

Fully-Specified Name

Component

Estimated date of delivery

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Est date of delivery

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.73

Common Test Rank Get Info

17949

Member of these Panels

Language Variants Get Info

Related Names

• CLIN
• EDC
• EDD
• Est date of delivery
• Finding
• Findings
• Narrative
• Point in time
• Random
• Report

29762-2 Coded social history

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

Language Variants Get Info