LOINC
Version 2.71

68781-4Pediatric pulmonology History and physical noteActive

Part Description

LP72701-3   History and physical note
History and physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. Source: HL7

Fully-Specified Name

Component
History and physical note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Pediatric pulmonology

Additional Names

Short Name
Peds pulmonology H&P note

Associated Observations

This panel contains the recommended sections for history and physical notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
Indent48765-2 Alerts R
Indent51848-0 Assessment R
Indent51847-2 Assessment+Plan R
Indent10154-3 Chief complaint R
Indent10157-6 Family history R
Indent10210-3 General status R
Indent10164-2 History of present illness O
Indent11369-6 History of immunizations O
Indent69730-0 Instructions O
Indent10160-0 Medications R
Indent11348-0 Past medical history R
Indent29545-1 Physical examination R
Indent18776-5 Plan of care R
Indent11450-4 Problems O
Indent47519-4 Procedures O
Indent29299-5 Reason for visit R
Indent46239-0 Reason for visit and Chief complaint R
Indent30954-2 Results (Diagnostic findings) R
Indent10187-3 Review of systems R
Indent29762-2 Social history R
Indent8716-3 Vital signs R

Associated Observations

This panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).

LOINC Name R/O/C Cardinality Example UCUM Units
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
Indent77599-9 Additional documentation R
Indent77598-1 Externally defined clinical data elements Document R
Indent47420-5 Functional status assessment note R
Indent77597-3 Orders placed Document R
Indent18776-5 Plan of care note R
Indent29762-2 Social history Narrative R
Indent77596-5 Transportation summary Document R
Indent42348-3 Advance directives O
Indent48765-2 Allergies R
Indent51847-2 Evaluation + Plan note R
Indent51848-0 Evaluation note R
Indent46239-0 Chief complaint+Reason for visit Narrative R
Indent10154-3 Chief complaint Narrative - Reported R
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative R
Indent10157-6 History of family member diseases Narrative R
Indent10210-3 Physical findings of General status Narrative R
Indent61146-7 Goals Narrative R
Indent75310-3 Health concerns Document R
Indent11383-7 Patient problem outcome Narrative R
Indent11348-0 History of Past illness Narrative R
Indent10164-2 History of Present illness Narrative R
Indent11369-6 History of Immunization Narrative R
Indent69730-0 Instructions R
Indent62387-6 Interventions Narrative R
Indent46264-8 History of medical device use R
Indent10160-0 History of Medication use Narrative R
Indent10190-7 Mental status Narrative R
Indent61144-2 Diet and nutrition Narrative R
Indent61149-1 Objective Narrative R
Indent48768-6 Payment sources Document R
Indent29545-1 Physical findings Narrative R
Indent11450-4 Problem list - Reported R
Indent47519-4 History of Procedures Document R
Indent42349-1 Reason for referral (narrative) R
Indent29299-5 Reason for visit Narrative R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent10187-3 Review of systems Narrative - Reported R
Indent61150-9 Subjective Narrative R
Indent8716-3 Vital signs R

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.38
Last Updated
Version 2.58
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38753-6 History and physical note|ANYRole|ANYSetting
LG39033-2 Pediatric pulmonology|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
病史与体格检查记录:发现:时间点:{环境}:文档型:儿科肺病学
it-ITItalian (Italy)
Anamnesi e nota fisica:Osservazione:Pt:{Setting}:Doc:Pneumologia pediatrica

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=68781-4