Version 2.80

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

LOINC Long Common Name
57083-8 Labor and Delivery record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Ιστορικό εισαγωγής και κλινικής εξέτασης τοκετού - συνιστώμενο σετ IHE:-:Pt:{Ρυθμίσεις}:-:
Synonyms: Ιστορικό εισαγωγής και κλινικής εξέτασης τοκετού - συνιστώμενο σετ IHE
es-MX Spanish (Mexico) Historial de admisión de trabajo de parto y parto y examen físico: equipo IHE recomendado:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Travaglio e parto, anamnesi e visita di ricovero - set IHE raccomandato:-:Pt:{Setting}:-:
Synonyms: Panel documentazione Punto nel tempo (episodio)
zh-CN Chinese (China) 临产和分娩入院病史与体格检查 - 推荐 IHE 集合:-:时间点:{环境}:-:
Synonyms: 临产（阵痛）和分娩入院病史与体格检查（查体） - 推荐 IHE 集合;Integrating the Healthcare Enterprise;IHE;医疗机构集成;医疗保健企业集成 事件发生的地方;场景;环境;背景 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.文档;文书组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目）;文件医嘱组;医疗文书医嘱组;医疗文件医嘱组 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 组 组合 组合医嘱 组合类 组套

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
82811-1 Nurse summary note - recommended sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Κύριο παράπονο:Εύρεση:Pt:^Ασθενής:Nar:Αναφερόμενη
Synonyms: Εύρεση
es-AR Spanish (Argentina) motivo de consulta principal:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Queja principal:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Plainte principale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Disturbo principale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) belangrijkste klacht:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Основная жалоба:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 主诉:发现:时间点:^患者:叙述型:报告法
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 控诉;申诉;指控;不平;牢骚;委屈;意见;怨言;病痛;主诉 时刻;随机;随意;瞬间 病史与体格检查

10164-2 History of present illness

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese der aktuellen Krankheit:Anamnese:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Παρούσα ασθένεια:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad presente:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Malattia attuale:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) huidige ziekte:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
zh-CN Chinese (China) 现有疾病:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 现病史;目前疾病;当前疾病;现病 病史与体格检查

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
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

History of Past illness Narrative

Basic Attributes

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese früherer Krankheiten:Anamnese:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Προηγούμενη ασθένεια:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de enfermedades pasadas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad pasada:Hx:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Anamnèse. Maladies antérieures:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Malattie pregresse:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) ziektegeschiedenis:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История предыдущих заболеваний:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез заболеваний История Описательный Точка во времени;Момент
zh-CN Chinese (China) 既往病史:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 既往疾病史;既往疾病历史 时刻;随机;随意;瞬间 病史与体格检查

56838-6 History of infection

Reference Information

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

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

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Μολυσματική νόσος:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό Μολυσματική νόσος
es-MX Spanish (Mexico) Enfermedad infecciosa:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Malattia infettiva:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) besmettelijke ziekte:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
pt-BR Portuguese (Brazil) Histórico de doenças infecciosas:Achado:Pt:^Paciente:Nar:
Synonyms: ; Hx infectious disease; Finding; Findings; Point in time; Random; Narrative; Report; Dis
ru-RU Russian (Russian Federation) Инфекционная болезнь:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Точка во времени;Момент
zh-CN Chinese (China) 传染病:历史记录:时间点:^患者:叙述型:
Synonyms: 传染性疾病 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 疾 病 病史与体格检查 症

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

LOINC Long Common Name
81898-9 Composite triage and nursing note - recommended IHE set
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese früherer Schwangerschaften:Anamnese:Zeitpunkt:Reproduktionssystem:Freitext:
el-GR Greek (Greece) Ιστορικό εγκυμοσύνης:Ιστορικό:Pt:Αναπαραγωγικό σύστημα:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de embarazos:hallazgo:punto en el tiempo:sistema reproductor:Narrativo:informado
es-MX Spanish (Mexico) Historia de embarazos:Hx:Punto temporal:Sistema reproductivo:Narrativo:
fr-BE French (Belgium) Anamnèse grossesses:Hx:Temps ponctuel:Système reproducteur:Narratif:
it-IT Italian (Italy) Storia di gravidanze:Hx:Pt:Apparato riproduttivo:Nar:
Synonyms: Anamnesi Apparato riproduttore Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) zwangerschapshistorie:voorgeschiedenis:moment:voortplantingsstelsel:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История беременностей:Hx:ТчкВрм:Репродуктивная система:Опис:
Synonyms: Акушерский анамнез История Описательный Точка во времени;Момент
zh-CN Chinese (China) 妊娠史:历史记录:时间点:生殖系统:叙述型:
Synonyms: 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 怀孕;怀孕期;妊娠期;妊娠类;妊娠（复数） 怀孕史;妊娠历史 时刻;随机;随意;瞬间 病史与体格检查

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
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Social history Narrative

Basic Attributes

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

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Sozialanamnese:Befund:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Κοινωνικό ιστορικό:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση
es-AR Spanish (Argentina) antecedentes sociales:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Historia social:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Histoire sociale:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Storia sociale:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) sociale geschiedenis:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Histórico social:Achado:Pt:^Paciente:Nar:
Synonyms: ; Social Hx; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Социальная история:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Социальный анамнез Точка во времени;Момент
zh-CN Chinese (China) 社会史:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 社会历史

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
Property
Hx
Time
Pt
System
^Family member
Scale
Nar
Method

Long Common Name

History of family member diseases Narrative

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73 (MIN)
Change Reason
Previous Releases: Changed Property from "Find" to "Hx", removed Method of "Reported" and corrected System from Family to ^Family member to align with existing family history terms and to represent family member as a Super System per 8/2015 Clinical LOINC Committee decision;
Common Test Rank Get Info
9825

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
35089-2 History and physical panel
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
35090-0 Patient history
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Ιστορικό ασθενειών μελών οικογένειας:Ιστορικό:Pt:^Μέλος οικογένειας:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de enfermedades en miembros familiares:hallazgo:punto en el tiempo:familia:Narrativo:informado
es-MX Spanish (Mexico) Historia de enfermedades de miembros de la familia:Hx:Punto temporal:^ Miembro de la familia:Narrativo:
fr-BE French (Belgium) Anamnèse. Maladies dans la famille:Hx:Temps ponctuel:^membre de famille:Narratif:
fr-CA French (Canada) Antécédents familiaux:Histoire:Temps ponctuel:^membre de famille:Narratif:
it-IT Italian (Italy) Storia di malattie di membri familiari:Hx:Pt:^membro della famiglia:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Storia di malattie di membri della famiglia Storia;Anamnesi
nl-NL Dutch (Netherlands) geschiedenis van ziekte binnen de familie:voorgeschiedenis:moment:^familielid:tekstueel:
Synonyms: anamnese ziekte in familieanamnese
ru-RU Russian (Russian Federation) История член семьи заболевания:Hx:ТчкВрм:^семьи член:Опис:
Synonyms: История Описательный Семейный анамнез заболеваний Точка во времени;Момент
zh-CN Chinese (China) 家族成员疾病史:历史记录:时间点:^家庭成员:叙述型:
Synonyms: 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 家人;家族成员;超系统 - 家庭成员 家庭 家族成员病史;家属疾病史;家属病史;家庭成员疾病史;家庭成员病史 时刻;随机;随意;瞬间 病史与体格检查

10187-3 Review of systems

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

LOINC Long Common Name
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Ανασκόπηση συστημάτων:Εύρεση:Pt:^Ασθενής:Nar:Αναφερόμενη
Synonyms: Εύρεση
es-AR Spanish (Argentina) revisión de sistemas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Revisión de sistemas:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Revue des systèmes:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Esame di apparati:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) beoordeling van systemen:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Исследование по системам:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Точка во времени;Момент
zh-CN Chinese (China) 系统评审:发现:时间点:^患者:叙述型:报告法
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 系统回顾;系统审核

29545-1 Physical exam

Fully-Specified Name

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

Long Common Name

Physical findings Narrative

Basic Attributes

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

Member of these Panels

LOINC Long Common Name
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Φυσικά ευρήματα:Εύρεση:Pt:^Ασθενής:Nar:Παρατηρηθέν
Synonyms: Εύρεση
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observado
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
fr-BE French (Belgium) Examen physique:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:^Paciente:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查（查体、体检、身体检查、肉体检查）发现（所见）;查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 观测法

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
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Observed

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.73 (MIN)
Common Test Rank Get Info
576

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
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
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
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
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) Vitalparameter:Befund:Zeitpunkt:^Patient:Freitext:Beobachtet
el-GR Greek (Greece) Ζωτικά σημεία:Εύρεση:Pt:^Ασθενής:Nar:Παρατηρηθέν
Synonyms: Εύρεση Ζωτικά σημεία
es-MX Spanish (Mexico) Signos vitales:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:signos vitales:Narrativo:observado
fr-BE French (Belgium) Signes vitaux:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Segni vitali:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) vitale functies:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Sinais vitais:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Жизненно важные функции:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 生命体征:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 生命体征类;生命征象 病史与体格检查 观测法

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

LOINC Long Common Name
57083-8 Labor and Delivery record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σύνοψη τοκετού - συνιστώμενο σετ IHE:-:Pt:{Ρυθμίσεις}:-:
Synonyms: Σύνοψη τοκετού - συνιστώμενο σετ IHE
es-MX Spanish (Mexico) Resumen de trabajo de parto y parto: conjunto IHE recomendado:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Travaglio e parto, sintesi - set IHE raccomandato:-:Pt:{Setting}:-:
Synonyms: Panel documentazione Punto nel tempo (episodio)
zh-CN Chinese (China) 临产和分娩摘要 - 推荐 IHE 集合:-:时间点:{环境}:-:
Synonyms: 临产（阵痛）和分娩摘要（小结、概要、总结、梗概、概括、总汇） - 推荐 IHE 集合;Integrating the Healthcare Enterprise;IHE;医疗机构集成;医疗保健企业集成 事件发生的地方;场景;环境;背景 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.文档;文书组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目）;文件医嘱组;医疗文书医嘱组;医疗文件医嘱组 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 组 组合 组合医嘱 组合类 组套

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

LOINC Long Common Name
69459-6 Care record summary panel
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 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
59271-7 Hospital discharge summary panel
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82811-1 Nurse summary note - recommended sections
62863-6 PhenX domain - Infectious diseases and immunity
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
el-GR Greek (Greece) Διάγνωση εισιτηρίου:Imp:Pt:^Ασθενής:Nar:Αναφερόμενη
Synonyms: Imp Διάγνωση εισιτηρίου
es-MX Spanish (Mexico) Admisión hospitalaria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Documents admission hôpital:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Ricovero ospedaliero, Dx:Imp:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Diagnosi di ricovero ospedaliero;Diagnosi di ammis Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis opnamediagnose:interpretatie:moment:^patiënt:tekstueel:rapportage
pt-BR Portuguese (Brazil) Admissão hospitalar Dx:Imp:Pt:^Paciente:Nar:Relatado
Synonyms: Hosp; Interpretation; Interp; Impression; Impressions; Point in time; Random; Narrative; Report; Diagnosis
ru-RU Russian (Russian Federation) Госпитализация Dx:Впчт:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Впечатление/интерпретация исследования Диагноз госпитализации Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院入院诊断:印象:时间点:^患者:叙述型:报告法
Synonyms: Dx 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 病院 诊断（Diagnosis，Dx） 院

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
82811-1 Nurse summary note - recommended sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Κύριο παράπονο:Εύρεση:Pt:^Ασθενής:Nar:Αναφερόμενη
Synonyms: Εύρεση
es-AR Spanish (Argentina) motivo de consulta principal:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Queja principal:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Plainte principale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Disturbo principale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) belangrijkste klacht:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Основная жалоба:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 主诉:发现:时间点:^患者:叙述型:报告法
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 控诉;申诉;指控;不平;牢骚;委屈;意见;怨言;病痛;主诉 时刻;随机;随意;瞬间 病史与体格检查

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

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

Member of these Panels

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

Language Variants Get Info

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

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
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
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
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) Medikationsanamnese:Anamnese:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Χρήση φαρμακευτικής αγωγής:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de consumo de medicaciones:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Uso de medicación:Hx:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Anamnèse. Utilsation médications:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Uso di farmaci:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) medicijngebruik:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese geneesmiddelen
ru-RU Russian (Russian Federation) История лекарственный препарат употребления:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Лекарственный анамнез Описательный Точка во времени;Момент
zh-CN Chinese (China) 用药史:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 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 时刻;随机;随意;瞬间 病史与体格检查 药物使用历史;药物使用史

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 2.63 (MIN)
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

LOINC Long Common Name
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
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

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) Σημείωμα Αξιολόγησης+Σχεδίου:Εύρεση:Pt:{Ρυθμίσεις}:Doc:{Ρόλος}
Synonyms: Εύρεση Σημείωμα Αξιολόγησης+Σχεδίου Σημείωση
es-MX Spanish (Mexico) Evaluación + nota del plan:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Valutazione+Nota di piano:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato Valutazione + Nota di piano
zh-CN Chinese (China) 评价+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 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 评价（评估、测评、评测、评判、评定、判定、评量、核定）+计划记录;评估+计划记录;评估与计划记录 评估 评定 鉴定

30954-2 Coded results

Fully-Specified Name

Component
Relevant diagnostic tests &or laboratory data
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Relevant diagnostic tests/laboratory data Narrative

Basic Attributes

Class
VACCIN
Type
Clinical
First Released
Version 2.04
Last Updated
Version 2.63 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
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
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
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
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA 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
102087-4 Secretin stimulation/Gastrin XXX challenge panel
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Relevante diagnostische Tests &oder Labordaten:Befund:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Σχετικές διαγνωστικές εξετάσεις και/ή εργαστηριακά δεδομένα:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Σχετικές διαγνωστικές εξετάσεις και/ή εργαστηριακά δεδομένα
es-AR Spanish (Argentina) pruebas diagnósticas relevantes y/o información de laboratorio:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Pruebas de diagnóstico o datos de laboratorio relevantes:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Test de diagnostic utiles et données de laboratoire:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Test diagnostici rilevanti &o dati di laboratorio:Osservazione:Pt:^Paziente:Nar:
Synonyms: Osservazione paziente Punto nel tempo (episodio) Test diagnostici rilevanti/dati di laboratorio Vaccinazioni
nl-NL Dutch (Netherlands) relevante diagnostische tests en/of laboratoriumgegevens:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Testes diagnósticos relevantes e/ou dados laboratóriais:Achado:Pt:^Paciente:Nar:
Synonyms: ; Relevant Dx tests/lAc data; Finding; Findings; Point in time; Random; Narrative; Report; VACCINE
ru-RU Russian (Russian Federation) Значимый диагностический тест &или лабораторные данные:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 相关诊断试验和或实验室数据: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 接种;接种记录;疫苗;疫苗接种 时刻;随机;随意;瞬间 检验科;化验室;化验科 相关诊断试验/实验室数据;相关诊断试验和或实验室资料;相关诊断试验和或实验室检验数据;相关诊断试验和或检验数据;相关诊断试验和或化验数据

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese der aktuellen Krankheit:Anamnese:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Παρούσα ασθένεια:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad presente:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Malattia attuale:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) huidige ziekte:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
zh-CN Chinese (China) 现有疾病:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 现病史;目前疾病;当前疾病;现病 病史与体格检查

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
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

History of Past illness Narrative

Basic Attributes

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese früherer Krankheiten:Anamnese:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Προηγούμενη ασθένεια:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de enfermedades pasadas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad pasada:Hx:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Anamnèse. Maladies antérieures:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Malattie pregresse:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) ziektegeschiedenis:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История предыдущих заболеваний:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез заболеваний История Описательный Точка во времени;Момент
zh-CN Chinese (China) 既往病史:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 既往疾病史;既往疾病历史 时刻;随机;随意;瞬间 病史与体格检查

56838-6 Coded history of infection

Reference Information

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

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

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Μολυσματική νόσος:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό Μολυσματική νόσος
es-MX Spanish (Mexico) Enfermedad infecciosa:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Malattia infettiva:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) besmettelijke ziekte:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
pt-BR Portuguese (Brazil) Histórico de doenças infecciosas:Achado:Pt:^Paciente:Nar:
Synonyms: ; Hx infectious disease; Finding; Findings; Point in time; Random; Narrative; Report; Dis
ru-RU Russian (Russian Federation) Инфекционная болезнь:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Точка во времени;Момент
zh-CN Chinese (China) 传染病:历史记录:时间点:^患者:叙述型:
Synonyms: 传染性疾病 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 疾 病 病史与体格检查 症

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

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

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

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

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

LOINC Long Common Name
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) Πλάνο τοκετού:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Πλάνο τοκετού
es-MX Spanish (Mexico) Plan de nacimiento:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Nascita, piano:Osservazione:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo Osservazione paziente Piano di nascita Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) geboorteplan:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Plano de parto:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Роды план:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 出生计划:发现:时间点:^患者:叙述型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查

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

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

29545-1 Coded physical exam

Fully-Specified Name

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

Long Common Name

Physical findings Narrative

Basic Attributes

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

Member of these Panels

LOINC Long Common Name
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Φυσικά ευρήματα:Εύρεση:Pt:^Ασθενής:Nar:Παρατηρηθέν
Synonyms: Εύρεση
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observado
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
fr-BE French (Belgium) Examen physique:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:^Paciente:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查（查体、体检、身体检查、肉体检查）发现（所见）;查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 观测法

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

LOINC Long Common Name
81898-9 Composite triage and nursing note - recommended IHE set
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese früherer Schwangerschaften:Anamnese:Zeitpunkt:Reproduktionssystem:Freitext:
el-GR Greek (Greece) Ιστορικό εγκυμοσύνης:Ιστορικό:Pt:Αναπαραγωγικό σύστημα:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de embarazos:hallazgo:punto en el tiempo:sistema reproductor:Narrativo:informado
es-MX Spanish (Mexico) Historia de embarazos:Hx:Punto temporal:Sistema reproductivo:Narrativo:
fr-BE French (Belgium) Anamnèse grossesses:Hx:Temps ponctuel:Système reproducteur:Narratif:
it-IT Italian (Italy) Storia di gravidanze:Hx:Pt:Apparato riproduttivo:Nar:
Synonyms: Anamnesi Apparato riproduttore Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) zwangerschapshistorie:voorgeschiedenis:moment:voortplantingsstelsel:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История беременностей:Hx:ТчкВрм:Репродуктивная система:Опис:
Synonyms: Акушерский анамнез История Описательный Точка во времени;Момент
zh-CN Chinese (China) 妊娠史:历史记录:时间点:生殖系统:叙述型:
Synonyms: 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 怀孕;怀孕期;妊娠期;妊娠类;妊娠（复数） 怀孕史;妊娠历史 时刻;随机;随意;瞬间 病史与体格检查

57060-6 Estimated delivery dates

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

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

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

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.

Fully-Specified Name

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

Long Common Name

Social history Narrative

Basic Attributes

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

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Sozialanamnese:Befund:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Κοινωνικό ιστορικό:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση
es-AR Spanish (Argentina) antecedentes sociales:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Historia social:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Histoire sociale:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Storia sociale:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) sociale geschiedenis:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Histórico social:Achado:Pt:^Paciente:Nar:
Synonyms: ; Social Hx; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Социальная история:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Социальный анамнез Точка во времени;Момент
zh-CN Chinese (China) 社会史:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 社会历史

18610-6 Medications administered

Fully-Specified Name

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

Long Common Name

Medication administered Set

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

57072-1 Intravenous fluids administered

Term Description

The intravenous fluids administered section shall contain a narrative description of fluids administered to a patient during the course of an encounter.

Reference Information

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

Fully-Specified Name

Component
Intravenous fluids administered
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Intravenous fluids administered Narrative

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
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
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Χορηγούμενα ενδοφλέβια υγρά:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Χορηγούμενα ενδοφλέβια υγρά
es-MX Spanish (Mexico) Se administran líquidos por vía intravenosa:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Liquidi intravenosi somministrati:Osservazione:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) intraveneus toegediende vloeistoffen:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Líquidos intravenosos administrados:Achado:Pt:^Paciente:Nar:
Synonyms: ; IV fluids administered; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Внутривенные жидкости введены:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 所施用的静脉内液体:发现:时间点:^患者:叙述型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 所给予的静脉内（静脉内注射、静注、IV）液体（输液） 时刻;随机;随意;瞬间 病史与体格检查

57073-9 Prenatal events

Term Description

A collection of information containing pertinent prenatal information that has a direct impact on the process of labor and delivery.

Reference Information

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

Fully-Specified Name

Component
Prenatal records
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Long Common Name

Prenatal records

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.66 (NAM)
Change Reason
Previous Releases: ; Updated Component from "Prenatal events" to "Prenatal records" and Scale from "Nar" to "Doc" based on review with the HL7 Attachments Workgroup.
HL7® Attachment Structure
No IG exists

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
62863-6 PhenX domain - Infectious diseases and immunity

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Προγεννητικά αρχεία:Εύρεση:Pt:^Ασθενής:Doc:
Synonyms: Εύρεση Προγεννητικά αρχεία
es-MX Spanish (Mexico) Registros prenatales:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Prenatale, registri:Osservazione:Pt:^Paziente:Doc:
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) Registri prenatali
nl-NL Dutch (Netherlands) prenataal verslag:bevinding:moment:^patiënt:document:
pt-BR Portuguese (Brazil) Eventos pré-natal:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
zh-CN Chinese (China) 产前记录: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 产前（出生前的、胎儿期、出生以前的）记录（档案） 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 时刻;随机;随意;瞬间 病史与体格检查

10167-5 List of surgeries

Fully-Specified Name

Component
Surgical procedures
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

History of Surgical procedures Narrative

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73 (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;
Common Test Rank Get Info
18927

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
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) Χειρουργικές επεμβάσεις:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de procedimientos quirúrgicos:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Procedimientos quirúrgicos:Hx:Punto temporal:^ Paciente:Narrativo:
fr-CA French (Canada) Antécédents chirurgicaux:Histoire:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Procedure chirurgiche:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) chirurgische ingrepen:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese operaties
zh-CN Chinese (China) 外科手术操作项目类:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 外科手术（外科学手术、手术）操作项目类（操作类、操作项目、操作） 时刻;随机;随意;瞬间 病史与体格检查

57074-7 Labor and delivery process

Term Description

The Labor and Delivery Section SHALL include a narrative text containing relevant information collected during the labor and delivery process

Reference Information

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

Fully-Specified Name

Component
Labor and delivery process
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Labor and delivery process Narrative

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
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) Διαδικασία τοκετού:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Διαδικασία τοκετού Εύρεση
es-MX Spanish (Mexico) Proceso de trabajo de parto y parto:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Travaglio e parto, processo:Osservazione:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo Osservazione paziente Processo di travaglio e parto Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verloop zwangerschap en bevalling:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Processo de trabalho e parto:Achado:Pt:^Paciente:Nar:
Synonyms: ; L&D process; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Роды и родоразрешение процесс:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 临产和分娩过程:发现:时间点:^患者:叙述型:
Synonyms: 临产（阵痛）和分娩过程;阵痛和分娩过程;分娩过程 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查

57075-4 Newborn delivery information

Term Description

A collection of information obtained at birth and up to the transfer of the infant from the birthing room to a post-natal unit.

Part Descriptions

LP281763-5   ^Newborn
Newborn refers to an infant during the hospital stay in which he/she was born. Terms with "Newborn" are used for concepts recorded in the mother's record. Source: Regenstrief LOINC

Reference Information

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

Fully-Specified Name

Component
Newborn delivery information
Property
Find
Time
Pt
System
^Newborn
Scale
Doc
Method

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.68 (MAJ)
Change Reason
Release 2.68: DefinitionDescription: Broaden use-case of term description.; SCALE_TYP: Updated to current LOINC model for representing a collection of information.; Previous Releases:

Member of these Panels

LOINC Long Common Name
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) Πληροφορίες τοκετού νεογνού:Εύρεση:Pt:^Νεογνό:Doc:
Synonyms: Εύρεση Πληροφορίες τοκετού νεογνού
es-MX Spanish (Mexico) Información sobre el parto del recién nacido:Tipo:Punto temporal:^ Recién nacido:Documento:
it-IT Italian (Italy) Neonato, informazioni parto:Osservazione:Pt:^neonato:Doc:
Synonyms: Esame obbiettivo Informazioni sul parto del neonato Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) informatie bevalling nieuwgeborene:bevinding:moment:^pasgeborene:document:
pt-BR Portuguese (Brazil) Parto do recém nascido informações:Achado:Pt:^Recem nascido:Nar:
Synonyms: ; NB delivery info; Finding; Findings; Point in time; Random; New born; Narrative; Report
ru-RU Russian (Russian Federation) Новорождённый родоразрешение информация:Находка:ТчкВрм:^новорожденный:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 新生儿分娩信息:发现:时间点:^新生儿: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 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 初生儿;超系统 - 新生儿 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 新生儿分娩（娩出、生产）信息 时刻;随机;随意;瞬间 病史与体格检查

55103-6 Estimated blood loss

Fully-Specified Name

Component
Surgical operation note estimated blood loss
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Surgical operation note estimated blood loss Narrative

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σημείωμα χειρουργικής επέμβασης: εκτιμώμενη απώλεια αίματος:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Αίμα Απώλεια αίματος Εύρεση Σημείωμα χειρουργικής επέμβασης Σημείωμα χειρουργικής επέμβασης: εκτιμώμενη απώλεια αίματος Σημείωση
es-MX Spanish (Mexico) Nota de operación quirúrgica pérdida de sangre estimada:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Nota di operazione chirurgica, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:
Synonyms: Nota di intervento chirurgico Osservazione paziente Perdita di sangue stimata in nota di intervento ch Procedura chirurgica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag geschat bloedverlies:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Послеоперационный эпикриз Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录 预计失血量:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 失血量;出血;出血量;血液损失 手术操作记录 预计失血量;外科手术操作记录 预计失血量;手术记录 预计失血量;外科手术记录 估计失血量;外科手术记录 预计失血 手术操作记录;外科手术操作记录;手术记录 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书 血;全血

57078-8 Coded antenatal testing and surveillance

Term Description

The Antenatal Testing and Surveillance section shall contain a narrative description of reports and data from tests and surveilllance performed during the pregnancy (e.g. Ultrasound, Biophysicial Profile, Non-Stress Test, Contraction Stress Test)

Reference Information

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

Fully-Specified Name

Component
Antenatal testing and surveillance
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Antenatal testing and surveillance Narrative

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63 (MIN)

Member of these Panels

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

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Pränatale Testung und Überwachung:Befund:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Προγεννητικός έλεγχος και επιτήρηση:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Προγεννητικός έλεγχος και επιτήρηση
es-MX Spanish (Mexico) Pruebas y vigilancia prenatales:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Test e sorveglianza antenatale:Osservazione:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) antenatale testen en toezicht:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Teste pré-natal e vigilância:Achado:Pt:^Paciente:Nar:
Synonyms: ; Antenatal testing & surveillance; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Антенатальное тестирование и надзор:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Дородовые исследования и наблюдение Описательный Точка во времени;Момент
zh-CN Chinese (China) 出生前测试与监测:发现:时间点:^患者:叙述型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 出生前（怀孕期、产前）测试（检测、测试、检验）与监测（监视、监督、监控）;出生前的测试与监测;怀孕期测试与监测;产前测试与监测 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查

92576-8 Maternal discharge summary - recommended IHE set

Term Description

The recommended set of LOINC terms for the IHE Maternal Discharge Summary (MDS) profile, a content profile that defines the structure of the data collected from delivery until discharge from the birthing facility. It includes, but is not limited to demographics, medications, laboratory results, newborn delivery information, patient education, and outcomes.

Fully-Specified Name

Component
Maternal discharge 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 2.79 (PANEL)
Panel Type
Convenience group

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σύνοψη εξιτηρίου μητρός - συνιστώμενο σετ IHE:-:Pt:{Ρυθμίσεις}:-:
Synonyms: Σύνοψη εξιτηρίου μητρός - συνιστώμενο σετ IHE
es-MX Spanish (Mexico) Resumen del alta materna: equipo IHE recomendado:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Maternal Discharge Summary - set IHE raccomandato:-:Pt:{Setting}:-:
Synonyms: Panel documentazione Punto nel tempo (episodio)
zh-CN Chinese (China) 产妇出院摘要 - 推荐 IHE 集合:-:时间点:{环境}:-:
Synonyms: 事件发生的地方;场景;环境;背景 产妇（母亲、孕产妇、妈妈）出院摘要摘要（小结、概要、总结、梗概、概括、总汇） - 推荐 IHE 集合;Integrating the Healthcare Enterprise;IHE;医疗机构集成;医疗保健企业集成 允许...离开(医院、军队);(从监狱)释放 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.文档;文书组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目）;文件医嘱组;医疗文书医嘱组;医疗文件医嘱组 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 组 组合 组合医嘱 组合类 组套

8648-8 Hospital course

Term Description

Hospital course describes the sequence of events from admission to discharge in a hospital facility.

Fully-Specified Name

Component
Hospital course
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Hospital course Narrative

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary 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
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set
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
el-GR Greek (Greece) Νοσοκομειακή πορεία:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Νοσοκομειακή πορεία
es-MX Spanish (Mexico) Curso hospitalario:Tipo:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) curso hospitalario:hallazgo:punto en el tiempo:^paciente:Narrativo:
fr-BE French (Belgium) Séjour hospitalier:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Decorso ospedaliero:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis verloop:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Curso do hospital:Achado:Pt:^Paciente:Nar:
Synonyms: Hosp; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Госпитальный курс:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Курс лечения в стационаре Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院病程: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 医院过程;住院治疗情况记录 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 病院 院

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

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

11535-2 Discharge diagnosis

Term Description

Hospital discharge diagnosis describes the patient's relevant problems or diagnoses that occurred during the hospitalization or that need to be followed after hospitalization.

Fully-Specified Name

Component
Hospital discharge Dx
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Hospital discharge Dx Narrative

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 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
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set
82811-1 Nurse summary note - recommended 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
el-GR Greek (Greece) Διάγνωση εξιτηρίου:Imp:Pt:^Ασθενής:Nar:
Synonyms: Imp
es-AR Spanish (Argentina) diagnóstico al alta del hospital:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Alta hospitalaria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Documents sortie hôpital:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, Dx:Imp:Pt:^Paziente:Nar:
Synonyms: Anamnesi Diagnosi di dimissione ospedaliera Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis onslagdiagnose:interpretatie:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Alta hospitalar Dx:Imp:Pt:^Paciente:Nar:
Synonyms: Hosp; Interpretation; Interp; Impression; Impressions; Point in time; Random; Narrative; Report; Diagnosis
ru-RU Russian (Russian Federation) Госпитализация выбытие Dx:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Выписка Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院诊断:印象:时间点:^患者:叙述型:
Synonyms: Dx 允许...离开(医院、军队);(从监狱)释放 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 病院 诊断（Diagnosis，Dx） 院

10183-2 Hospital discharge medications

Term Description

Hospital discharge medications defines the medications that the patient is intended to take (or stop) after discharge. This may also include a patient's prescription history and indicate the source of the medication list, for example, from a pharmacy system versus from the patient.

Fully-Specified Name

Component
Hospital discharge medications
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Hospital discharge medications Narrative

Basic Attributes

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

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 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
59271-7 Hospital discharge summary panel
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Φαρμακευτική αγωγή εξιτηρίου από το νοσοκομείο:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση
es-AR Spanish (Argentina) medicación para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Medicamentos para el alta hospitalaria:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Médications sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, farmaci:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Farmaci di dimissione ospedaliera Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis ontslagmedicatie:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Госпитализация выбытие лекарственные препараты:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Выписка Лекарства Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院药物:发现:时间点:^患者:叙述型:
Synonyms: 允许...离开(医院、军队);(从监狱)释放 出院药物（用药、药物治疗、药物处理） 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 医院出院后用药 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 病院 药物类;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 院

30954-2 Coded results

Fully-Specified Name

Component
Relevant diagnostic tests &or laboratory data
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Relevant diagnostic tests/laboratory data Narrative

Basic Attributes

Class
VACCIN
Type
Clinical
First Released
Version 2.04
Last Updated
Version 2.63 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
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
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
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
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA 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
102087-4 Secretin stimulation/Gastrin XXX challenge panel
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Relevante diagnostische Tests &oder Labordaten:Befund:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Σχετικές διαγνωστικές εξετάσεις και/ή εργαστηριακά δεδομένα:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Σχετικές διαγνωστικές εξετάσεις και/ή εργαστηριακά δεδομένα
es-AR Spanish (Argentina) pruebas diagnósticas relevantes y/o información de laboratorio:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Pruebas de diagnóstico o datos de laboratorio relevantes:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Test de diagnostic utiles et données de laboratoire:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Test diagnostici rilevanti &o dati di laboratorio:Osservazione:Pt:^Paziente:Nar:
Synonyms: Osservazione paziente Punto nel tempo (episodio) Test diagnostici rilevanti/dati di laboratorio Vaccinazioni
nl-NL Dutch (Netherlands) relevante diagnostische tests en/of laboratoriumgegevens:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Testes diagnósticos relevantes e/ou dados laboratóriais:Achado:Pt:^Paciente:Nar:
Synonyms: ; Relevant Dx tests/lAc data; Finding; Findings; Point in time; Random; Narrative; Report; VACCINE
ru-RU Russian (Russian Federation) Значимый диагностический тест &или лабораторные данные:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 相关诊断试验和或实验室数据: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 接种;接种记录;疫苗;疫苗接种 时刻;随机;随意;瞬间 检验科;化验室;化验科 相关诊断试验/实验室数据;相关诊断试验和或实验室资料;相关诊断试验和或实验室检验数据;相关诊断试验和或检验数据;相关诊断试验和或化验数据

11493-4 Coded hospital discharge studies summary

Fully-Specified Name

Component
Hospital discharge studies summary
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Hospital discharge studies summary Narrative

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary 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
59271-7 Hospital discharge summary panel
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Περίληψη μελετών κατά το εξιτήριο από το νοσοκομείο:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση
es-AR Spanish (Argentina) resumen de los estudios para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Resumen de estudios de alta hospitalaria:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Résumé des études de sortie hospitalière:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, sintesi esami:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) Sintesi esami in dimissione ospedaliera
nl-NL Dutch (Netherlands) ziekenhuis ontslag samenvatting onderzoeken:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Госпитализация выбытие исследования краткие сведения:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Выписка Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院检查摘要:发现:时间点:^患者:叙述型:
Synonyms: 允许...离开(医院、军队);(从监狱)释放 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 医院出院检查摘要（小结、概要、总结、梗概、概括、总汇） 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 病院 院

38212-7 Pain scale assessment

Fully-Specified Name

Component
Pain assessment panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Long Common Name

Pain assessment panel

Basic Attributes

Class
PANEL.H&P
Type
Clinical
First Released
Version 2.13
Last Updated
Version 2.69 (PANEL)
Order vs. Observation
Order
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
57083-8 Labor and Delivery record panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Πίνακας αξιολόγησης πόνου:-:Pt:^Ασθενής:-:
Synonyms: Αξιολόγηση Αξιολόγηση πόνου Πίνακας αξιολόγησης πόνου
es-AR Spanish (Argentina) PAIN ASSESSMENT PANEL:-:punto en el tiempo:^PATIENT:-:
es-MX Spanish (Mexico) Panel de evaluación del dolor:-:Punto temporal:^ Paciente:-:
it-IT Italian (Italy) Dolore, panel valutazione:-:Pt:^Paziente:-:
Synonyms: Panel valutazione del dolore paziente Punto nel tempo (episodio) Set di prescrizione per anamnesi e esame obiettivo Valutazione del dolore
nl-NL Dutch (Netherlands) pijn vaststellingspanel:-:moment:^patiënt:-:
pt-BR Portuguese (Brazil) Avaliação da dor painel:-:Pt:^Paciente:-:
Synonyms: ; Pain Assessment Pnl; Point in time; Random; Pan; Panl
ru-RU Russian (Russian Federation) Боль оценка панель:-:ТчкВрм:^Пациент:-:
Synonyms: Точка во времени;Момент
zh-CN Chinese (China) 疼痛评估组套:-:时间点:^患者:-:
Synonyms: 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.病史与体格检查小节;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）.历史纪录与体格检查;医嘱组.历史纪录与体格检查小节;医嘱组.病史与体格检查;历史纪录与体格检查医嘱组;历史纪录与体格检查医嘱组类;历史纪录与体格检查小节医嘱组;历史纪录与体格检查小节医嘱组类;病史与体格检查医嘱组;病史与体格检查医嘱组类;病史与体格检查小节医嘱组;病史与体格检查小节医嘱组类 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 疼;痛;痛苦;悲痛;苦恼 疼痛评估（评价、估计、估价、评论、估定、估算） 疼痛评估（评价、估计、估价、评论、估定、估算）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） 病史与体格检查 组 组合 组合医嘱 组合类 组套 评价;估计;估价;评论;估定;估算

38209-3 Pain exacerbating factors - Reported

Fully-Specified Name

Component
Pain exacerbating factors
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.13
Last Updated
Version 2.27 (MIN)

Member of these Panels

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
57083-8 Labor and Delivery record panel
38212-7 Pain assessment panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Παράγοντες επιδείνωσης του πόνου:Εύρεση:Pt:^Ασθενής:Nom:Αναφερόμενη
Synonyms: Εύρεση Παράγοντες επιδείνωσης Παράγοντες επιδείνωσης του πόνου
es-AR Spanish (Argentina) PAIN EXACERBATING FACTORS:hallazgo:punto en el tiempo:^PATIENT:Nominal:informado
es-MX Spanish (Mexico) Factores que exacerban el dolor:Tipo:Punto temporal:^ Paciente:Nominal:Reported
it-IT Italian (Italy) Dolore, fattori esacerbanti:Osservazione:Pt:^Paziente:Nom:Riportato
Synonyms: Anamnesi Fattori di esacerbazione del dolore Osservazione paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Fatores de exarcebação da dor:Achado:Pt:^Paciente:Nom:Relatado
Synonyms: Finding; Findings; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Боль усиливающие факторы:Находка:ТчкВрм:^Пациент:Ном:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 疼痛加重因素: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 恶化因素;加剧因素 时刻;随机;随意;瞬间 疼;痛;痛苦;悲痛;苦恼 疼痛加剧因素;疼痛恶化因素 病史与体格检查

38227-5 Braden score

Fully-Specified Name

Component
Braden scale score.total
Property
Score
Time
Pt
System
^Patient
Scale
Qn
Method
Observed.Braden scale

Long Common Name

Braden scale total score

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.13
Last Updated
Version 2.73 (MIN)
Change Reason
Previous Releases: We made an administrative decision to define the total scores from various survey instruments as Quantitative rather than ordinal. There is no intention to change the existing meaning.;
Common Test Rank Get Info
866

Member of these Panels

LOINC Long Common Name
38228-3 Braden scale skin assessment panel
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Example Units

Unit Source
{score} Example UCUM Units

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
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

History of Past illness Narrative

Basic Attributes

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese früherer Krankheiten:Anamnese:Zeitpunkt:^Patient:Freitext:
el-GR Greek (Greece) Προηγούμενη ασθένεια:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Ιστορικό
es-AR Spanish (Argentina) antecedentes de enfermedades pasadas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad pasada:Hx:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Anamnèse. Maladies antérieures:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Malattie pregresse:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) ziektegeschiedenis:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История предыдущих заболеваний:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез заболеваний История Описательный Точка во времени;Момент
zh-CN Chinese (China) 既往病史:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 既往疾病史;既往疾病历史 时刻;随机;随意;瞬间 病史与体格检查

57076-2 Post-partum treatment

Term Description

The Post-partum Treatment Section shall include a narrative description of the treatment delivered to the mother susequent to the delivery.

Reference Information

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

Fully-Specified Name

Component
Postpartum hospitalization treatment
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Postpartum hospitalization treatment Narrative

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Θεραπεία νοσηλείας μετά τον τοκετό:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Θεραπεία νοσηλείας μετά τον τοκετό Νοσηλεία
es-MX Spanish (Mexico) Tratamiento de hospitalización posparto:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Post-partum, terapia ricovero:Osservazione:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) Storia di ospedalizzazioni Trattamento in ricovero post parto;Trattamento in
nl-NL Dutch (Netherlands) ziekenhuisbehandeling post partum:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Tratamento hospitalar pós-parto:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report; Postpartm; Postpart
ru-RU Russian (Russian Federation) Послеродовая госпитализация лечение:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез госпитализаций Описательный Точка во времени;Момент
zh-CN Chinese (China) 产后住院治疗:发现:时间点:^患者:叙述型:
Synonyms: 产后医院治疗;产后住院治疗治疗手段（方法、措施） 产后的 住院治疗历史; 医院收容史;送入医院;留诊史;住院史 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 在产后 时刻;随机;随意;瞬间 病史与体格检查

57072-1 Intravenous fluids administered

Term Description

The intravenous fluids administered section shall contain a narrative description of fluids administered to a patient during the course of an encounter.

Reference Information

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

Fully-Specified Name

Component
Intravenous fluids administered
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Intravenous fluids administered Narrative

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
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
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Χορηγούμενα ενδοφλέβια υγρά:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Εύρεση Χορηγούμενα ενδοφλέβια υγρά
es-MX Spanish (Mexico) Se administran líquidos por vía intravenosa:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Liquidi intravenosi somministrati:Osservazione:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) intraveneus toegediende vloeistoffen:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Líquidos intravenosos administrados:Achado:Pt:^Paciente:Nar:
Synonyms: ; IV fluids administered; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Внутривенные жидкости введены:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 所施用的静脉内液体:发现:时间点:^患者:叙述型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 所给予的静脉内（静脉内注射、静注、IV）液体（输液） 时刻;随机;随意;瞬间 病史与体格检查

55103-6 Estimated blood loss

Fully-Specified Name

Component
Surgical operation note estimated blood loss
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

Surgical operation note estimated blood loss Narrative

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σημείωμα χειρουργικής επέμβασης: εκτιμώμενη απώλεια αίματος:Εύρεση:Pt:^Ασθενής:Nar:
Synonyms: Αίμα Απώλεια αίματος Εύρεση Σημείωμα χειρουργικής επέμβασης Σημείωμα χειρουργικής επέμβασης: εκτιμώμενη απώλεια αίματος Σημείωση
es-MX Spanish (Mexico) Nota de operación quirúrgica pérdida de sangre estimada:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Nota di operazione chirurgica, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:
Synonyms: Nota di intervento chirurgico Osservazione paziente Perdita di sangue stimata in nota di intervento ch Procedura chirurgica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag geschat bloedverlies:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Послеоперационный эпикриз Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录 预计失血量:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 失血量;出血;出血量;血液损失 手术操作记录 预计失血量;外科手术操作记录 预计失血量;手术记录 预计失血量;外科手术记录 估计失血量;外科手术记录 预计失血 手术操作记录;外科手术操作记录;手术记录 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书 血;全血

56836-0 Transfusion history

Reference Information

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

Fully-Specified Name

Component
Blood transfusion
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Long Common Name

History of Blood transfusion Narrative

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.73 (MIN)
Change Reason
Previous Releases: Removed "History of" from Component and changed Property from "Find" to "Hx" per 8/2015 Clinical LOINC Committee decision;
Common Test Rank Get Info
10793

Member of these Panels

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Μετάγγιση αίματος:Ιστορικό:Pt:^Ασθενής:Nar:
Synonyms: Αίμα Ιστορικό Μετάγγιση αίματος
es-MX Spanish (Mexico) Transfusión de sangre:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Trasfusione di sangue:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) bloedtransfusie:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
pt-BR Portuguese (Brazil) Histórico de transfusões sanguíneas:Achado:Pt:^Paciente:Nar:
Synonyms: ; Hx blood transfusion; Finding; Findings; Point in time; Random; Narrative; Report; Tx
ru-RU Russian (Russian Federation) История крови переливания:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Точка во времени;Момент Трансфузионный анамнез
zh-CN Chinese (China) 输血:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 注入 灌输 病史与体格检查 血;全血 血库成分 - 输血 输注 输液 输血史;血液输注 输血法

34895-3 Patient education and consents

Fully-Specified Name

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

Long Common Name

Education note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.11
Last Updated
Version 2.73 (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
Common Test Rank Get Info
4357

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38762-7 Education note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Εκπαιδευτικό σημείωμα:Εύρεση:Pt:{Ρυθμίσεις}:Doc:{Ρόλος}
Synonyms: Εκπαιδευτικό σημείωμα Εύρεση Σημείωση
es-AR Spanish (Argentina) EDUCATION NOTE:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}
es-MX Spanish (Mexico) Nota educativa:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Nota educativa:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) opleidingsverslag:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 教育记录: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 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 教育（培训、训练）记录;培训记录;训练记录 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

57077-0 Newborn status at maternal discharge

Term Description

The Newborn Status at Maternal Discharge section shall contain a narrative description of the status and disposition of the newborn at the time of maternal discharge.

Part Descriptions

LP281763-5   ^Newborn
Newborn refers to an infant during the hospital stay in which he/she was born. Terms with "Newborn" are used for concepts recorded in the mother's record. Source: Regenstrief LOINC

Reference Information

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

Fully-Specified Name

Component
Newborn status at maternal discharge
Property
Find
Time
Pt
System
^Newborn
Scale
Nar
Method

Long Common Name

Newborn status at maternal discharge from Newborn Narrative

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Κατάσταση νεογνού κατά το εξιτήριο μητρός:Εύρεση:Pt:^Νεογνό:Nar:
Synonyms: Εύρεση Κατάσταση Κατάσταση νεογνού κατά το εξιτήριο μητρός
es-MX Spanish (Mexico) Estado del recién nacido al alta de la madre:Tipo:Punto temporal:^ Recién nacido:Narrativo:
it-IT Italian (Italy) Neonato, stato alla dimissione della madre:Osservazione:Pt:^neonato:Nar:
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio) Stato del neonato al momento della dimissione dell
nl-NL Dutch (Netherlands) status nieuwgeborene bij ontslag moeder:bevinding:moment:^pasgeborene:tekstueel:
pt-BR Portuguese (Brazil) Estado do recém nascido na alta materna:Achado:Pt:^Recem nascido:Nar:
Synonyms: ; NB status at maternal discharge; Finding; Findings; Point in time; Random; New born; Narrative; Report
ru-RU Russian (Russian Federation) Новорождённый статус при мать выбытие:Находка:ТчкВрм:^новорожденный:Опис:
Synonyms: Выписка Описательный Состояние новорождённого при выписке матери Точка во времени;Момент
zh-CN Chinese (China) 产妇出院时的新生儿状态:发现:时间点:^新生儿:叙述型:
Synonyms: 产妇出院时的新生儿状况 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 允许...离开(医院、军队);(从监狱)释放 初生儿;超系统 - 新生儿 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 状况;情况 病史与体格检查