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.

Fully-Specified Name

Component

Labor and delivery admission history and physical - recommended IHE set

Property

-

Time

Pt

System

{Setting}

Scale

-

Method

Basic Attributes

Class

PANEL.DOC

Type

Clinical

First Released

Version 2.66

Last Updated

Version 2.66 (ADD)

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).

Fully-Specified Name

Component

Chief complaint

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Long Common Name

Chief complaint Narrative - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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.

Fully-Specified Name

Component

Present illness

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Present illness Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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.

Fully-Specified Name

Component

Past illness note

Property

Hx

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

History of Past illness note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; 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

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• H+P
• H+P.HX
• History
• Last
• notes
• P prime
• Point in time
• Random
• Visit note

56838-6 History of infection

Reference Information

Fully-Specified Name

Component

Infectious disease

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Infectious disease Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.63 (MIN)

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

Long Common Name

History of pregnancies Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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.

Fully-Specified Name

Component

Social history note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Social history note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H+P
• H+P.HX
• Hx
• notes
• P prime
• Point in time
• Random
• Social Hx
• Social hx note
• Visit note

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.

Fully-Specified Name

Component

History of family member diseases note

Property

Hx

Time

Pt

System

^Family member

Scale

Doc

Method

Long Common Name

History of family member diseases note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; 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

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Fam Mem
• Family member diseases Hx
• H/O
• H+P
• H+P.HX
• History
• Hx
• Hx of fam member ds note
• notes
• P prime
• Point in time
• Random
• Visit note

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.

Fully-Specified Name

Component

Review of systems

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Long Common Name

Review of systems Narrative - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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 note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Long Common Name

Physical findings note

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• notes
• P prime
• Phys find
• Point in time
• Random
• Visit note

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.

Fully-Specified Name

Component

Vital signs note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Long Common Name

Vital signs note

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Common Test Rank Get Info

576

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H+P
• H+P.PX
• notes
• P prime
• Point in time
• Random
• Visit note

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.

Fully-Specified Name

Component

Labor and delivery summary - recommended IHE set

Property

-

Time

Pt

System

{Setting}

Scale

-

Method

Basic Attributes

Class

PANEL.DOC

Type

Clinical

First Released

Version 2.66

Last Updated

Version 2.66 (ADD)

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

Long Common Name

Hospital admission diagnosis Narrative - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

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).

Fully-Specified Name

Component

Chief complaint

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Long Common Name

Chief complaint Narrative - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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

Long Common Name

Transport mode EMS system

Basic Attributes

Class

ED

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.63 (MIN)

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.

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Medication use Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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.

Fully-Specified Name

Component

Evaluation+Plan note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

Evaluation + Plan Note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.81 (MIN)

Change Reason

Release 2.81: ValidHL7AttachmentRequest: Updated to add to HIPAA Attachments, per user request.; 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

HL7^® Attachment Structure

No IG exists

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 note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Relevant diagnostic tests/laboratory data note

Basic Attributes

Class

VACCIN

Type

Clinical

First Released

Version 2.04

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Relevant Dx tests/lab data
• Relevant dx tests/lab data note
• VACCINE
• Visit note

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.

Fully-Specified Name

Component

Present illness

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Present illness Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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.

Fully-Specified Name

Component

Past illness note

Property

Hx

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

History of Past illness note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; 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

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• H+P
• H+P.HX
• History
• Last
• notes
• P prime
• Point in time
• Random
• Visit note

56838-6 Coded history of infection

Reference Information

Fully-Specified Name

Component

Infectious disease

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Infectious disease Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.63 (MIN)

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.

Fully-Specified Name

Component

Advance healthcare directives

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

Advance Healthcare Directives

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

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Adv healthcare directives
• 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.

Reference Information

Fully-Specified Name

Component

Birth plan

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

Birth plan Narrative

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.73 (MIN)

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.

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Allergies and adverse reactions Document

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

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 note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Long Common Name

Physical findings note

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• notes
• P prime
• Phys find
• Point in time
• Random
• Visit note

10162-6 Pregnancy history

Fully-Specified Name

Component

History of pregnancies

Property

Hx

Time

Pt

System

Reproductive system

Scale

Nar

Method

Long Common Name

History of pregnancies Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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

Long Common Name

Estimated date of delivery Narrative

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

Language Variants Get Info