Version 2.78

8646-2 Hospital admission diagnosis

Fully-Specified Name

Component
Hospital admission Dx
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Hospital admission Dx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.27
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
71531-8 ESRD hospitalization panel
59271-7 Hospital discharge summary panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) diagnóstico al ingreso al hospital:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
es-MX Spanish (Mexico) Admisión hospitalaria Dx:Interpretación:Punto temporal:^ Paciente:Nominal:
fr-BE French (Belgium) Documents admission hôpital:Impression/interprétation d'étude:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Ricovero ospedaliero, Dx:Imp:Pt:^Paziente:Nom:
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:nominaal:
pt-BR Portuguese (Brazil) Admissão hospitalar Dx:Imp:Pt:^Paciente:Nom:
Synonyms: Hosp; Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal; Diagnosis
ru-RU Russian (Russian Federation) Госпитализация Dx:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Диагноз госпитализации Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 医院入院诊断:印象:时间点:^患者:名义型:
Synonyms: Dx 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 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 时刻;随机;随意;瞬间 病史与体格检查 病院 诊断（Diagnosis，Dx） 院

46241-6 Hospital admission diagnosis Narrative - Reported

Fully-Specified Name

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

Additional Names

Short Name
Hospital admission Dx Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.19
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

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
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

42347-5 Admission diagnosis (narrative)

Fully-Specified Name

Component
Admission diagnosis
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 2.16
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
81218-0 Discharge summary - recommended C-CDA R2.1 sections
59271-7 Hospital discharge summary panel

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Ricovero, diagnosi:Osservazione:Pt:^Paziente:Nar:
Synonyms: Allegato Allegato referto clinico Diagnosi al momento del ricovero Osservazione paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Diagnóstico de internação:Achado:Pt:^Paciente:Nar:
Synonyms: ; Dx; Admission Dx; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Госпитализация диагноз:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Диагноз при госпитализации Описательный Точка во времени;Момент
zh-CN Chinese (China) 入院诊断:发现:时间点:^患者:叙述型:
Synonyms: 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 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 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 诊断结论;判断;结论

8649-6 Hospital discharge date

Fully-Specified Name

Component
Hospital discharge date
Property
TmStp
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Hospital discharge date

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
78000-7 Case notification panel [CDC.PHIN]
71531-8 ESRD hospitalization panel
59271-7 Hospital discharge summary panel
62863-6 PhenX domain - Infectious diseases and immunity
97782-7 Spine Tango Surgery 2017

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Krankenhausentlassdatum:Zeitstempel:Zeitpunkt:^Patient:Quantitativ:
es-AR Spanish (Argentina) fecha de alta del hospital:marca de tiempo:fecha y hora:punto en el tiempo:^paciente:cuantitativo:
es-MX Spanish (Mexico) Fecha de alta hospitalaria:TmStp:Punto temporal:^ Paciente:Cuantitativo:
it-IT Italian (Italy) Dimissione ospedaliera, data:TmStp:Pt:^Paziente:Qn:
Synonyms: Anamnesi Data di dimissione ospedaliera paziente Punto nel tempo (episodio) Time stamp (Data e Ora)
pt-BR Portuguese (Brazil) Data da alta hospitalar:TmStp:Pt:^Paciente:Qn:
Synonyms: Hosp; Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Госпитализация дата выбытие:TmStp:ТчкВрм:^Пациент:Колич:
Synonyms: Time Stamp (Дата и Время) Выписка Дата выписки Дата выписки из стационара Количественный Точка во времени;Момент
zh-CN Chinese (China) 医院出院日期:时间戳:时间点:^患者:定量型:
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 印时戳;时标;时间戳(日期与时间);时间标记;计时标记 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 日子;几号 时刻;随机;随意;瞬间 病史与体格检查 病院 院

8650-4 Hospital discharge disposition Narrative

Part Descriptions

LP72749-2   Hospital discharge disposition
The hospital discharge status or disposition of the patient having a hospitalization associated with the encounter at the emergency department. Source: Centers for Disease Control and Prevention

Fully-Specified Name

Component
Hospital discharge disposition
Property
Type
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hosp discharge dispo

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.52

Member of these Panels

LOINC Long Common Name
59271-7 Hospital discharge summary panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) decisión de alta del hospital:tipo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Disposición de alta hospitalaria:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Dimissione ospedaliera, disposizioni:Tipo:Pt:^Paziente:Nar:
Synonyms: Anamnesi Disposizioni di dimissione ospedaliera paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Disposição de alta hospitalar:Tipo:Pt:^Paciente:Nar:
Synonyms: Hosp; Typ; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Госпитализация выбытие диспозиция:Тип:ТчкВрм:^Пациент:Опис:
Synonyms: Выписка Диспозиция при выписке из стационара Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院去向:类型:时间点:^患者:叙述型:
Synonyms: 允许...离开(医院、军队);(从监狱)释放 出院安排 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 医院出院处置;医院出院安置;醫院出院動向;醫院出院後安置;病院出院動向;医院出院后安置;医院出院后安排 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 型 处理;安排;布置 时刻;随机;随意;瞬间 病史与体格检查 病院 院

38999-9 Hospital discharge DRG [Interpretation]

Term Description

Carries the discharge DRG code defined by CMS for setting Medicare's payment for a hospitalization.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Hospital discharge DRG
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Hospital Discharge DRG Imp

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.15
Last Updated
Version 2.50
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
59271-7 Hospital discharge summary panel
75854-0 PCORnet common data model set - version 1.0 [PCORnet]
85057-8 PCORnet Common Data Model set - version 3.0 [PCORnet]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Alta hospitalaria DRG:Interpretación:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Dimissione ospedaliera, DRG:Imp:Pt:^Paziente:Nom:
Synonyms: Anamnesi DRG di dimissione ospedaliera Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Alta hospitalar DRG:Imp:Pt:^Paciente:Nom:
Synonyms: Diagnosis related groups; Hosp; Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal; Diagnostic Related Groups
ru-RU Russian (Russian Federation) Госпиталь выбытие DRG:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Выписка КСГ при выписке из медицинской организации Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 医院出院诊断相关组:印象:时间点:^患者:名义型:
Synonyms: DRG DRGs 允许...离开(医院、军队);(从监狱)释放 出院 DRG;出院诊断相关组;医院出院 DRG;diagnosis-related group;诊断相关组;DRG 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 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 时刻;随机;随意;瞬间 疾病诊断关系群 疾病诊断相关分组 病史与体格检查 病院 诊断关系组 诊断关系群 诊断关联群 诊断相关人群 诊断相关分组 诊断相关组（Diagnostic Related Groups，DRG，DRGs） 院

8651-2 Hospital discharge Dx

Fully-Specified Name

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

Additional Names

Short Name
Hospital discharge Dx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.27
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
71531-8 ESRD hospitalization panel
59271-7 Hospital discharge summary panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) diagnóstico al alta del hospital:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
es-MX Spanish (Mexico) Alta hospitalaria Dx:Interpretación:Punto temporal:^ Paciente:Nominal:
fr-BE French (Belgium) Documents sortie hôpital:Impression/interprétation d'étude:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Dimissione ospedaliera, Dx:Imp:Pt:^Paziente:Nom:
Synonyms: Anamnesi Diagnosi di dimissione ospedaliera Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis onslagdiagnose:interpretatie:moment:^patiënt:nominaal:
pt-BR Portuguese (Brazil) Alta hospitalar Dx:Imp:Pt:^Paciente:Nom:
Synonyms: Hosp; Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal; Diagnosis
ru-RU Russian (Russian Federation) Госпитализация выбытие Dx:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Выписка Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 医院出院诊断:印象:时间点:^患者:名义型:
Synonyms: Dx 允许...离开(医院、军队);(从监狱)释放 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 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 时刻;随机;随意;瞬间 病史与体格检查 病院 诊断（Diagnosis，Dx） 院

11544-4 Hospital discharge follow-up Narrative

Fully-Specified Name

Component
Hospital discharge follow-up
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hospital discharge follow-up

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
59271-7 Hospital discharge summary panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) seguimiento luego del alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Seguimiento del alta hospitalaria:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Suivi de sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, follow-up:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Follow-up di dimissione ospedaliera Osservazione paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Alta hospitalar acompanhamento:Achado:Pt:^Paciente:Nar:
Synonyms: Hosp; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Госпитализация выбытие последующее наблюдение:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Выписка Наблюдение после выписки из стационара Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院随访: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 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

8652-0 Hospital discharge history

Fully-Specified Name

Component
Hospital discharge history
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Hospital discharge Hx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
35089-2 History and physical panel
59271-7 Hospital discharge summary panel
35090-0 Patient history

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) antecedentes del alta hospitalaria:hallazgo:punto en el tiempo:^paciente:Nominal:
es-MX Spanish (Mexico) Historial de alta hospitalaria:Tipo:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Dimissione ospedaliera, storia:Osservazione:Pt:^Paziente:Nom:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) Storia di dimissione ospedaliera
pt-BR Portuguese (Brazil) Histórico de alta hospitalar:Achado:Pt:^Paciente:Nom:
Synonyms: ; Hospital discharge Hx; Hosp; Finding; Findings; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Госпитализация выбытие история:Находка:ТчкВрм:^Пациент:Ном:
Synonyms: Выписка Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 医院出院史:发现:时间点:^患者:名义型:
Synonyms: 允许...离开(医院、军队);(从监狱)释放 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 医院出院历史 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 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 病院 院

8653-8 Hospital Discharge instructions

Fully-Specified Name

Component
Discharge instructions
Property
Find
Time
Pt
System
Hospital
Scale
Doc
Method
{Role}

Additional Names

Short Name
Hosp Discharge instruct

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.67
Change Reason
Updated term to represent the current LOINC Document Ontology model.; 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
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

Member of these Groups Get Info

LOINC Group Group Name
LG38843-5 Discharge instructions|ANYRole|ANYSetting
LG41829-9 Hospital|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Entlassungsanweisungen:Befund:Zeitpunkt:Krankenhaus:Dokument:{Funktion}
es-AR Spanish (Argentina) instrucciones para el alta del hospital:texto:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Instrucciones de descarga:Tipo:Punto temporal:Hospital:Documento:{Role}
it-IT Italian (Italy) Istruzioni di dimissione:Osservazione:Pt:Ospedale:Doc:{Role}
Synonyms: Documentazione dell''ontologia Istruzioni al momento della dimissione Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) ontslagaanwijzingen:bevinding:moment:ziekenhuis:document:{rol}
pt-BR Portuguese (Brazil) Instruções de alta hospitalar:Txt:Pt:^Paciente:Nar:
Synonyms: Hosp; Text; Point in time; Random; Narrative; Report
zh-CN Chinese (China) 出院指导:发现:时间点:医院: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 使用说明;指令;指令说明;指导;指示;教育;说明书;说明类 允许...离开(医院、军队);(从监狱)释放 出院医嘱;出院（离院）指导（医嘱） 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 病院;院

10183-2 Hospital discharge medications Narrative

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.
Source: Regenstrief LOINC

Fully-Specified Name

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

Additional Names

Short Name
Hospital discharge medications

Basic Attributes

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

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
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

8654-6 Hospital discharge medications

Fully-Specified Name

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

Additional Names

Short Name
Hospital discharge medications

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
59271-7 Hospital discharge summary panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Krankenhausentlassmedikation:Befund:Zeitpunkt:^Patient:Nominal:
es-AR Spanish (Argentina) medicación para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Nominal:
es-MX Spanish (Mexico) Medicamentos para el alta hospitalaria:Tipo:Punto temporal:^ Paciente:Nominal:
fr-BE French (Belgium) Médications sortie hôpital:Observation:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Dimissione ospedaliera, farmaci:Osservazione:Pt:^Paziente:Nom:
Synonyms: Anamnesi Farmaci di dimissione ospedaliera Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis ontslagmedicatie:bevinding:moment:^patiënt:nominaal:
pt-BR Portuguese (Brazil) Medicações de alta hospitalar:Achado:Pt:^Paciente:Nom:
Synonyms: Hosp; Finding; Findings; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Госпитализация выбытие лекарственные препараты:Находка:ТчкВрм:^Пациент:Ном:
Synonyms: Выписка Лекарства Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 医院出院药物:发现:时间点:^患者:名义型:
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） 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 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 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

10184-0 Hospital discharge physical findings Narrative

Term Description

Hospital discharge physical findings records a narrative description of the patient's physical findings.
Source: Regenstrief LOINC

Fully-Specified Name

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

Additional Names

Short Name
Hospital discharge physical findings

Basic Attributes

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

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

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Krankenhausentlassbefund der körperlichen Untersuchungen:Befund:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) hallazgos físicos al momento del alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Hallazgos físicos al alta hospitalaria:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Examen physique de sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione Osservazioni fisiche in dimissione ospedaliera paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis ontslag lichamelijke bevindingen:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Госпитализация выбытие физикальные находки:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Выписка Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院体格检查发现:发现:时间点:^患者:叙述型:
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 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 医院出院体格检查（查体、体检、身体检查、肉体检查）发现（所见）;医院出院查体发现;医院出院查体所见 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

8655-3 Hospital discharge procedures

Fully-Specified Name

Component
Hospital discharge procedures
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Hospital discharge procedures

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
59271-7 Hospital discharge summary panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) procedimientos para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Nominal:
es-MX Spanish (Mexico) Procedimientos de alta hospitalaria:Tipo:Punto temporal:^ Paciente:Nominal:
fr-BE French (Belgium) Procédures de sortie hospitalière:Observation:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Dimissione ospedaliera, procedure:Osservazione:Pt:^Paziente:Nom:
Synonyms: Anamnesi Osservazione paziente Procedure di dimissione ospedaliera Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Procedimentos de alta hospitalar:Achado:Pt:^Paciente:Nom:
Synonyms: Hosp; Finding; Findings; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Госпитализация выбытие вмешательства:Находка:ТчкВрм:^Пациент:Ном:
Synonyms: Выписка Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 医院出院操作项目:发现:时间点:^患者:名义型:
Synonyms: 允许...离开(医院、军队);(从监狱)释放 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 医院出院操作;医院出院手续 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 时刻;随机;随意;瞬间 病史与体格检查 病院 院

11493-4 Hospital discharge studies summary Narrative

Fully-Specified Name

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

Additional Names

Short Name
Hospital discharge studies summary

Basic Attributes

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

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
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

34105-7 Hospital Discharge summary

Part Descriptions

LP72467-1   Discharge summary note
Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition and disposition at discharge, information provided to the patient and family, and provisions for follow-up care. Source: HL7

Fully-Specified Name

Component
Discharge summary note
Property
Find
Time
Pt
System
Hospital
Scale
Doc
Method
{Role}

Additional Names

Short Name
Hosp D/C sum

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.09
Last Updated
Version 2.73
Change Reason
Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
Order vs. Observation
Both
HL7® Attachment Structure
IG exists

Member of these Panels

LOINC Long Common Name
59271-7 Hospital discharge summary panel

Member of these Groups Get Info

LOINC Group Group Name
LG38746-0 Discharge summary note|ANYRole|ANYSetting
LG41829-9 Hospital|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Krankenhausentlassbericht - Notiz:Befund:Zeitpunkt:Krankenhaus:Dokument:{Funktion}
es-AR Spanish (Argentina) nota de resumen en el momento del alta:hallazgo:punto en el tiempo:hospital:Documento:{proveedor}
es-MX Spanish (Mexico) Nota de resumen de alta:Tipo:Punto temporal:Hospital:Documento:{Role}
it-IT Italian (Italy) Lettera di dimissione ospedaliera:Osservazione:Pt:Ospedale:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) samenvattende ontslagbrief:bevinding:moment:ziekenhuis:document:{rol}
zh-CN Chinese (China) 出院摘要记录:发现:时间点:医院: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 允许...离开(医院、军队);(从监狱)释放 出院（离院）摘要（小结、概要、总结、梗概、概括、总汇）记录;出院总结记录;出院概要记录;出院概括记录;出院摘要;出院小结 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 小结;概要;概括;总汇;总结 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 病院;院 笔记;按语;注释;说明;票据;单据;证明书

34106-5 Physician Hospital Discharge summary

Part Descriptions

LP72467-1   Discharge summary note
Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition and disposition at discharge, information provided to the patient and family, and provisions for follow-up care. Source: HL7

Fully-Specified Name

Component
Discharge summary note
Property
Find
Time
Pt
System
Hospital
Scale
Doc
Method
Physician

Additional Names

Short Name
MD Hosp D/C sum

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.09
Last Updated
Version 2.73
Order vs. Observation
Both
HL7® Attachment Structure
IG exists

Member of these Panels

LOINC Long Common Name
59271-7 Hospital discharge summary panel

Member of these Groups Get Info

LOINC Group Group Name
LG38746-0 Discharge summary note|ANYRole|ANYSetting
LG41829-9 Hospital|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38946-6 Physician|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) nota de resumen en el momento del alta:hallazgo:punto en el tiempo:hospital:Documento:médico
es-MX Spanish (Mexico) Nota de resumen de alta:Tipo:Punto temporal:Hospital:Documento:Médico
it-IT Italian (Italy) Lettera di dimissione ospedaliera:Osservazione:Pt:Ospedale:Doc:Medico
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) samenvattende ontslagbrief:bevinding:moment:ziekenhuis:document:arts
zh-CN Chinese (China) 出院摘要记录:发现:时间点:医院:文档型:医师
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 允许...离开(医院、军队);(从监狱)释放 内科医师;内科医生;医生 出院（离院）摘要（小结、概要、总结、梗概、概括、总汇）记录;出院总结记录;出院概要记录;出院概括记录;出院摘要;出院小结 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 小结;概要;概括;总汇;总结 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 病院;院 笔记;按语;注释;说明;票据;单据;证明书