69459-6
Care record summary panel
Active
34133-9 Summarization of episode note
Term Description
This LOINC term is commonly used as the Clinical Document code for both the Care Record Summary (CRS) and Continuity of Care Document (CCD), with an "episode" of care defined as the provision of care over a specified period of time that can cover one or more health care encounters. This definition was approved by the LOINC Document Ontology subcommittee in February 2021.
Source: Regenstrief LOINC
Part Descriptions
LP73427-4 Summary of episode note
Summarization of Episode Note contains pertinent data about the provision of care for a patient over a specified period of time. Examples include a Care Record Summary (CRS) and Continuity of Care Document (CCD). CRS includes the summary of the episode, discharge and transfer. CCD includes the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters. Such documents are commonly used in Transfer of Care scenarios.
Source: HL7
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Summary of episode note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Summary of episode note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.09
- Last Updated
- Version 2.70
- Change Reason
- Release 2.70: DefinitionDescription: Added definition of "episode of care"; Previous Releases: Changed Component from 'Summarization of episode' per Clinical LOINC Committee decision to harmonize existing Document Ontology axes values.; 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 |
|---|---|
| 69459-6 | Care record summary panel |
| 48769-4 | Continuity of Care panel |
| 74293-2 | Oncology plan of care and summary - recommended CDA set |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38814-6 | Summary of episode note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Synonyms: Krankengeschichte |
| de-DE | German (Germany) | Zusammenfassung der Behandlungsepisode - Notiz: |
| es-AR | Spanish (Argentina) | nota con síntesis sobre el episodio: |
| es-MX | Spanish (Mexico) | Resumen de la nota del episodio: |
| it-IT | Italian (Italy) | Nota di sintesi di episodio: Synonyms: Documentazione dell''ontologia Nota di riepilogo di episodio Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | samenvatting van episode: |
| zh-CN | Chinese (China) | 病程摘要记录: Synonyms: 临床文档型; |
11348-0 History of Past illness Narrative
Term Description
History of past illness describes the history related to their current complaints, problems, or diagnoses.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Past illness
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Past illness
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;
Member of these Panels
| 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: |
| es-AR | Spanish (Argentina) | antecedentes de enfermedades pasadas: |
| es-MX | Spanish (Mexico) | Enfermedad pasada: |
| fr-BE | French (Belgium) | Anamnèse. Maladies antérieures: |
| it-IT | Italian (Italy) | Malattie pregresse: Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | ziektegeschiedenis: Synonyms: anamnese |
| ru-RU | Russian (Russian Federation) | История предыдущих заболеваний: Synonyms: Анамнез заболеваний История Описательный Точка во времени; |
| zh-CN | Chinese (China) | 既往病史: Synonyms: 医疗服务对象; |
46241-6 Hospital admission diagnosis Narrative - Reported
Observation Required in Panel
Optional
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: |
| fr-BE | French (Belgium) | Documents admission hôpital: |
| it-IT | Italian (Italy) | Ricovero ospedaliero, Dx: Synonyms: Anamnesi Diagnosi di ricovero ospedaliero; |
| nl-NL | Dutch (Netherlands) | ziekenhuis opnamediagnose: |
| pt-BR | Portuguese (Brazil) | Admissão hospitalar Dx: Synonyms: Hosp; |
| ru-RU | Russian (Russian Federation) | Госпитализация Dx: Synonyms: Анамнестические сведения; |
| zh-CN | Chinese (China) | 医院入院诊断: Synonyms: Dx 医疗服务对象; |
11535-2 Hospital discharge Dx
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.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Hospital discharge Dx
- Property
- Imp
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hospital discharge Dx
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- 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 |
| 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 |
|---|---|---|
| es-AR | Spanish (Argentina) | diagnóstico al alta del hospital: |
| es-MX | Spanish (Mexico) | Alta hospitalaria Dx: |
| fr-BE | French (Belgium) | Documents sortie hôpital: |
| it-IT | Italian (Italy) | Dimissione ospedaliera, Dx: Synonyms: Anamnesi Diagnosi di dimissione ospedaliera Impressione/interpretazione di studio paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | ziekenhuis onslagdiagnose: |
| pt-BR | Portuguese (Brazil) | Alta hospitalar Dx: Synonyms: Hosp; |
| ru-RU | Russian (Russian Federation) | Госпитализация выбытие Dx: Synonyms: Впечатление/интерпретация исследования Выписка Описательный Точка во времени; |
| zh-CN | Chinese (China) | 医院出院诊断: Synonyms: Dx 允许...离开(医院、 |
11450-4 Problem list
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Problem list
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nom
- Method
- Reported
Additional Names
- Short Name
- Problem list Reported
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Common Test Rank Get Info
- 9889
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 57082-0 | Antepartum record panel |
| 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 |
| 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 |
| 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 |
| 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 |
| 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) | Problemliste: |
| es-AR | Spanish (Argentina) | lista de problemas: |
| es-MX | Spanish (Mexico) | Lista de problemas: |
| fr-CA | French (Canada) | Liste des problèmes: |
| fr-BE | French (Belgium) | Liste de problèmes: |
| it-IT | Italian (Italy) | Lista dei problemi: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | probleemlijst: |
| pt-BR | Portuguese (Brazil) | Lista de problemas: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Проблем список: Synonyms: Анамнестические сведения; |
| zh-CN | Chinese (China) | 问题列表: Synonyms: 分类型应答; |
10155-0 History of allergies (Nar)
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Allergies
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Allergies
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 69459-6 | Care record summary panel |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
| 72062-3 | Medication allergies panel [ESRD] |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | antecedentes de alergias: |
| es-MX | Spanish (Mexico) | Alergias: |
| fr-CA | French (Canada) | Allergies: |
| it-IT | Italian (Italy) | Allergie: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | allergieën: Synonyms: anamnese |
| ru-RU | Russian (Russian Federation) | Аллергии: Synonyms: История Описательный Точка во времени; |
| zh-CN | Chinese (China) | 变态反应: Synonyms: 医疗服务对象; |
8658-7 History of allergies (Nom)
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Allergies
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nom
- Method
Additional Names
- Short Name
- Hx of Allergies
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0h(3)
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 69459-6 | Care record summary panel |
| 35089-2 | History and physical panel |
| 97065-7 | Medical history for preventive vaccination against COVID-19 (Coronavirus Disease 2019) - with mRNA vaccine |
| 35090-0 | Patient history |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | antecedentes de alergias: |
| es-MX | Spanish (Mexico) | Alergias: |
| fr-CA | French (Canada) | Allergies: |
| it-IT | Italian (Italy) | Allergie: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | allergieën: Synonyms: anamnese |
| pt-BR | Portuguese (Brazil) | Histórico de alergias: Synonyms: ; |
| ru-RU | Russian (Russian Federation) | Аллергии: Synonyms: История Номинальный; |
| zh-CN | Chinese (China) | 变态反应: Synonyms: 分类型应答; |
11382-9 Medication allergy - Reported
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Medication allergy
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nom
- Method
- Reported
Additional Names
- Short Name
- Medication allergy Reported
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.27
Example Answer List LL5328-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Aspirin | LA26702-3 | ||
| Iodine | LA30119-4 | ||
| Naproxen, ketoprofen or other non-steroidal | LA14348-9 | ||
| Penicillin | LA28487-9 | ||
| Sulfa drugs | LA30118-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 89070-7 | ADAPTABLE patient reported item set [ADAPTABLE] |
| 69459-6 | Care record summary panel |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | alergia a la medicación: |
| es-MX | Spanish (Mexico) | Alergia a medicamentos: |
| fr-CA | French (Canada) | Médicaments allergie: |
| fr-BE | French (Belgium) | Allergies médicaments: |
| it-IT | Italian (Italy) | Allergia ai farmaci: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| pt-BR | Portuguese (Brazil) | Alergia a medicação: Synonyms: History; |
| ru-RU | Russian (Russian Federation) | Лекарственный препарат аллергия: Synonyms: Анамнестические сведения; |
| zh-CN | Chinese (China) | 药物变态反应: Synonyms: Clem 的变态原分类 Clem 的变态反应分类 Clem 的过敏原分类 Clem 的过敏反应分类 分类型应答; |
10160-0 History of medication use
Term Description
History of medication use defines a patient's current medications and history of pertinent medications. This term may also include a patient's prescription and dispense history.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Medication use
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Medication use
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;
Member of these Panels
| 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: |
| es-AR | Spanish (Argentina) | antecedentes de consumo de medicaciones: |
| es-MX | Spanish (Mexico) | Uso de medicación: |
| fr-BE | French (Belgium) | Anamnèse. Utilsation médications: |
| it-IT | Italian (Italy) | Uso di farmaci: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | medicijngebruik: Synonyms: anamnese geneesmiddelen |
| ru-RU | Russian (Russian Federation) | История лекарственный препарат употребления: Synonyms: История Лекарственный анамнез Описательный Точка во времени; |
| zh-CN | Chinese (China) | 用药史: Synonyms: 医疗服务对象; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
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: |
| es-MX | Spanish (Mexico) | Medicamentos para el alta hospitalaria: |
| fr-BE | French (Belgium) | Médications sortie hôpital: |
| it-IT | Italian (Italy) | Dimissione ospedaliera, farmaci: Synonyms: Anamnesi Farmaci di dimissione ospedaliera Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | ziekenhuis ontslagmedicatie: |
| ru-RU | Russian (Russian Federation) | Госпитализация выбытие лекарственные препараты: Synonyms: Выписка Лекарства Описательный Точка во времени; |
| zh-CN | Chinese (China) | 医院出院药物: Synonyms: 允许...离开(医院、 |
42346-7 Medications on admission (narrative)
Term Description
Admission can refer to hospital admission, long-term care admission, or home health admission.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Medications on admission
- 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 |
|---|---|
| 69459-6 | Care record summary panel |
| 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 |
| 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) | Medikation bei Aufnahme: |
| fr-FR | French (France) | Traitement lors de l'admission: |
| fr-BE | French (Belgium) | Médications à admission: |
| it-IT | Italian (Italy) | Farmaci al ricovero: Synonyms: Allegato Allegato referto clinico Farmaci al momento del ricovero Osservazione paziente Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Medicamentos na internação: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Лекарственные препараты при госпитализации: Synonyms: Лекарства Описательный Точка во времени; |
| zh-CN | Chinese (China) | 入院时的药物: Synonyms: 临床报告信息附件; |
8648-8 Hospital course
Term Description
Hospital course describes the sequence of events from admission to discharge in a hospital facility.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Hospital course
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hospital course
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0h(3)
- 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 |
| 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 |
|---|---|---|
| es-AR | Spanish (Argentina) | curso hospitalario: |
| es-MX | Spanish (Mexico) | Curso hospitalario: |
| fr-BE | French (Belgium) | Séjour hospitalier: |
| it-IT | Italian (Italy) | Decorso ospedaliero: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | ziekenhuis verloop: |
| pt-BR | Portuguese (Brazil) | Curso do hospital: Synonyms: Hosp; |
| ru-RU | Russian (Russian Federation) | Госпитальный курс: Synonyms: Курс лечения в стационаре Описательный Точка во времени; |
| zh-CN | Chinese (China) | 医院病程: Synonyms: 医疗服务对象; |
10154-3 Chief complaint
Term Description
Chief complaint records the patient's primary complaint (the patient's own description).
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Chief complaint
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- Reported
Additional Names
- Short Name
- Chief complaint Reported
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.63
Member of these Panels
| 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 |
|---|---|---|
| es-AR | Spanish (Argentina) | motivo de consulta principal: |
| es-MX | Spanish (Mexico) | Queja principal: |
| fr-BE | French (Belgium) | Plainte principale: |
| it-IT | Italian (Italy) | Disturbo principale: Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | belangrijkste klacht: |
| ru-RU | Russian (Russian Federation) | Основная жалоба: Synonyms: Анамнестические сведения; |
| zh-CN | Chinese (China) | 主诉: Synonyms: 医疗服务对象; |
29299-5 Reason for visit
Term Description
This section records the patient's reason for their visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Reason for visit
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Reason for visit
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.63
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 |
| 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 |
| 59843-3 | Procedure note - recommended C-CDA R1.1 sections |
| 81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | motivo de la consulta: |
| es-MX | Spanish (Mexico) | Razón de la visita: |
| fr-CA | French (Canada) | Raison de visite: |
| fr-BE | French (Belgium) | Raison de consultation: |
| it-IT | Italian (Italy) | Motivo della visita: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | reden voor bezoek: |
| pt-BR | Portuguese (Brazil) | Motivo da visita: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Причина визит: Synonyms: Описательный Причина визита Точка во времени; |
| zh-CN | Chinese (China) | 关于就诊的原因: Synonyms: 关于就诊的理由; |
46239-0 Reason for visit and Chief complaint
Term Description
This term is used to record the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Chief complaint+Reason for visit
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Chief complaint+Reason for visit
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 |
| 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 |
| 59843-3 | Procedure note - recommended C-CDA R1.1 sections |
| 81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Queja principal + Motivo de la visita: |
| fr-BE | French (Belgium) | Plainte principale+raison de visite: |
| it-IT | Italian (Italy) | Disturbo principale+Motivo dell'incontro: Synonyms: Anamnesi Disturbo primario Disturbo primario e Motivo dell''incontro Lamenta Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | belangrijkste klacht + reden voor bezoek: |
| pt-BR | Portuguese (Brazil) | Reclamação à chefia+Motivo da visita: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Основная жалоба+Причина визита: Synonyms: Описательный Причина визита Проблема; |
| zh-CN | Chinese (China) | 主诉+就诊原因: Synonyms: 主诉+就诊理由; |
42349-1 Reason for referral
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Reason for referral
- 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 2.73
- Common Test Rank Get Info
- 2371
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 76464-7 | American Physical Therapy Association registry panel |
| 69459-6 | Care record summary panel |
| 72231-4 | Consultation note - recommended C-CDA R1.1 sections |
| 81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 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-AT | German (Austria) | Synonyms: Zuweisungsdiagnose |
| it-IT | Italian (Italy) | Motivo per rinvio: Synonyms: Allegato Allegato referto clinico Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | reden voor overplaatsing: |
| pt-BR | Portuguese (Brazil) | Motivo do encaminhamento: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Причина направления: Synonyms: Описательный Точка во времени; |
| zh-CN | Chinese (China) | 关于转诊的原因: Synonyms: 临床报告信息附件; |
42348-3 Advanced directives
Term Description
Advance directives contains data defining the patient's direction of care and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. Advance directives contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Advance directives
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Advance directives
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.16
- Last Updated
- Version 2.67
- Change Reason
- Previous Releases: Based on Clinical LOINC Committee review at the Feb. 2016 meeting, this term represents a document containing information on a patient's advance directives and any supporting documentation, such as a living will. The term was revised to fit the current LOINC Document Ontology model.;
- Order vs. Observation
- Both
Member of these Panels
| 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}| |
| LG51615-9 | Advance directives| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-DE | German (Germany) | Patientenverfügung: |
| de-AT | German (Austria) | Patientenverfügung: Synonyms: Beachtliche und verbindliche Patientenverfügungen |
| es-MX | Spanish (Mexico) | Directivas avanzadas: |
| fr-CA | French (Canada) | Directives médicales anticipée: |
| it-IT | Italian (Italy) | Dichiarazioni anticipate di trattamento: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato Testamenti biologici; |
| nl-NL | Dutch (Netherlands) | wilsverklaring: |
| pt-BR | Portuguese (Brazil) | Diretivas avançadas: Synonyms: Finding; |
| zh-CN | Chinese (China) | 事前指示类: Synonyms: 临床文档型; |
10164-2 History of present illness
Term Description
History of present illness describes the history related to the reason for a given procedure. It contains the historical details leading up to and pertaining to the patient's current complaint or reason for seeking medical care. Because history of present illness can include past surgical history and other procedures, the Procedure History section may be included under the History of Present Illness section or it may stand alone as its own section.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Present illness
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Pres illness
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;
Member of these Panels
| 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: |
| es-AR | Spanish (Argentina) | antecedentes de la enfermedad actual: |
| es-MX | Spanish (Mexico) | Enfermedad presente: |
| it-IT | Italian (Italy) | Malattia attuale: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | huidige ziekte: Synonyms: anamnese |
| zh-CN | Chinese (China) | 现有疾病: Synonyms: 医疗服务对象; |
10158-4 History of Functional status Narrative
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Functional status
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Functional status
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.56
- Change Reason
- 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 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | antecedentes del estado funcional: |
| es-MX | Spanish (Mexico) | Estado funcional: |
| it-IT | Italian (Italy) | Stato funzionale: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| ru-RU | Russian (Russian Federation) | Функциональный статус: Synonyms: История Описательный Точка во времени; |
| zh-CN | Chinese (China) | 功能状态: Synonyms: 功能状况; |
10157-6 History of family member diseases
Term Description
History of family member diseases is a report of health information, including medical, genetic, environmental, and lifestyle factors, pertaining to the patient and his or her genetic relatives (living or deceased). The family history information is used to determine possible or relevant health risk factors that may have a potential impact on the patient's healthcare risk profile.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- History of family member diseases
- Property
- Hx
- Time
- Pt
- System
- ^Family member
- Scale
- Nar
- Method
Additional Names
- Short Name
- Family member diseases Hx
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.73
- Change Reason
- Previous Releases: Changed Property from "Find" to "Hx", removed Method of "Reported" and corrected System from Family to ^Family member to align with existing family history terms and to represent family member as a Super System per 8/2015 Clinical LOINC Committee decision;
- Common Test Rank Get Info
- 9825
Member of these Panels
| 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 |
|---|---|---|
| es-AR | Spanish (Argentina) | antecedentes de enfermedades en miembros familiares: |
| es-MX | Spanish (Mexico) | Historia de enfermedades de miembros de la familia: |
| fr-BE | French (Belgium) | Anamnèse. Maladies dans la famille: |
| fr-CA | French (Canada) | Antécédents familiaux: |
| it-IT | Italian (Italy) | Storia di malattie di membri familiari: Synonyms: Anamnesi Punto nel tempo (episodio) Storia di malattie di membri della famiglia Storia; |
| nl-NL | Dutch (Netherlands) | geschiedenis van ziekte binnen de familie: Synonyms: anamnese ziekte in familieanamnese |
| ru-RU | Russian (Russian Federation) | История член семьи заболевания: Synonyms: История Описательный Семейный анамнез заболеваний Точка во времени; |
| zh-CN | Chinese (China) | 家族成员疾病史: Synonyms: 历史; |
29762-2 Social history
Term Description
The Social history section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Social history
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Social Hx
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.63
Member of these Panels
| 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: |
| es-AR | Spanish (Argentina) | antecedentes sociales: |
| es-MX | Spanish (Mexico) | Historia social: |
| fr-BE | French (Belgium) | Histoire sociale: |
| it-IT | Italian (Italy) | Storia sociale: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | sociale geschiedenis: |
| pt-BR | Portuguese (Brazil) | Histórico social: Synonyms: ; |
| ru-RU | Russian (Russian Federation) | Социальная история: Synonyms: Описательный Социальный анамнез Точка во времени; |
| zh-CN | Chinese (China) | 社会史: Synonyms: 医疗服务对象; |
11369-6 History of immunizations
Term Description
History of immunizations defines a patient's immunization status for the context and use case of the document type. Often included is current immunization status and possibly the entire immunization history.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Immunization
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Immunization
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Changed Component from "History of immunizations" to "Immunization", 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 |
|---|---|
| 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 |
| 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-AT | German (Austria) | Synonyms: Immunisierungsstatus |
| de-DE | German (Germany) | Impfanamnese: |
| es-AR | Spanish (Argentina) | antecedente de inmunización: |
| es-MX | Spanish (Mexico) | Inmunización: |
| fr-BE | French (Belgium) | Anamnèse. Immunisations: |
| it-IT | Italian (Italy) | Immunizzazioni: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | inenting: Synonyms: anamnese vaccinatie |
| ru-RU | Russian (Russian Federation) | История иммунизаций: Synonyms: История Описательный Точка во времени; |
| zh-CN | Chinese (China) | 疫苗接种史: Synonyms: 免疫接种历史; |
10167-5 History of surgical procedures
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Surgical procedures
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Surg proc
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.73
- 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 |
|---|---|---|
| es-AR | Spanish (Argentina) | antecedentes de procedimientos quirúrgicos: |
| es-MX | Spanish (Mexico) | Procedimientos quirúrgicos: |
| fr-CA | French (Canada) | Antécédents chirurgicaux: |
| it-IT | Italian (Italy) | Procedure chirurgiche: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | chirurgische ingrepen: Synonyms: anamnese operaties |
| zh-CN | Chinese (China) | 外科手术操作项目类: Synonyms: 医疗服务对象; |
46240-8 History of hospitalizations+History of outpatient visits
Term Description
History of hospitalizations and History of outpatient visits (i.e. Encounters) lists and describes any healthcare encounters pertinent to the patient's current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient's condition. It may include visits, appointments, as well as non face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Hospitalizations+Outpatient visits
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Hospitalizations+OP visits
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 2.19
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 69459-6 | Care record summary panel |
| 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 |
| 81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
| 51896-9 | Healthcare Associated Infection report - recommended CDA R2 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 |
| 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) | Hospitalizaciones + Visitas ambulatorias: |
| it-IT | Italian (Italy) | Ospedalizzazioni+Visite ambulatoriali: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | ziekenhuisopnames en poliklinische bezoeken: Synonyms: anamnese |
| pt-BR | Portuguese (Brazil) | Histórico de hospitalizações+ Histórico de visitas ambulatoriais: Synonyms: ; |
| ru-RU | Russian (Russian Federation) | История госпитализаций+История амбулаторных визитов: Synonyms: Анамнез госпитализаций+Анамнез амбулаторных посещений История Описательный Точка во времени; |
| zh-CN | Chinese (China) | 住院治疗史+门诊就诊史: Synonyms: 住院治疗历史+门诊就诊历史; |
11336-5 History of hospitalizations
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Hospitalization
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Hospitalization
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Changed Component from "History of hospitalizations" to "Hospitalization", 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 |
|---|---|
| 69459-6 | Care record summary panel |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
| 35089-2 | History and physical panel |
| 35090-0 | Patient history |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-ES | Spanish (Spain) | hospitalizacion: |
| es-AR | Spanish (Argentina) | antecedentes de hospitalizaciones: |
| es-MX | Spanish (Mexico) | Hospitalización: |
| fr-BE | French (Belgium) | Anamnèse.Hospitalisations: |
| it-IT | Italian (Italy) | Ospedalizzazioni: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia di ospedalizzazioni Storia; |
| nl-NL | Dutch (Netherlands) | ziekenhuisopname: Synonyms: anamnese |
| ru-RU | Russian (Russian Federation) | История госпитализаций: Synonyms: Анамнез госпитализаций История Описательный Точка во времени; |
| zh-CN | Chinese (China) | 住院治疗史: Synonyms: 住院治疗历史; |
11346-4 History of outpatient visits
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Outpatient visits
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Outpt visits
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 69459-6 | Care record summary panel |
| 55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | antecedentes de consultas ambulatorias: |
| es-MX | Spanish (Mexico) | Visitas ambulatorias: |
| it-IT | Italian (Italy) | Visite paziente esterno: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
| nl-NL | Dutch (Netherlands) | poliklinische bezoeken: Synonyms: anamnese |
| zh-CN | Chinese (China) | 门诊就诊类: Synonyms: 医疗服务对象; |
10187-3 Review of systems
Term Description
The Review of systems section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Review of systems
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- Reported
Additional Names
- Short Name
- Review of systems
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.63
Member of these Panels
| 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 |
|---|---|---|
| es-AR | Spanish (Argentina) | revisión de sistemas: |
| es-MX | Spanish (Mexico) | Revisión de sistemas: |
| fr-BE | French (Belgium) | Revue des systèmes: |
| it-IT | Italian (Italy) | Esame di apparati: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | beoordeling van systemen: |
| ru-RU | Russian (Russian Federation) | Исследование по системам: Synonyms: Анамнестические сведения; |
| zh-CN | Chinese (China) | 系统评审: Synonyms: 医疗服务对象; |
10184-0 Hospital discharge physical
Term Description
Hospital discharge physical findings records a narrative description of the patient's physical findings.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
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: |
| es-AR | Spanish (Argentina) | hallazgos físicos al momento del alta del hospital: |
| es-MX | Spanish (Mexico) | Hallazgos físicos al alta hospitalaria: |
| fr-BE | French (Belgium) | Examen physique de sortie hôpital: |
| it-IT | Italian (Italy) | Dimissione ospedaliera, osservazioni fisiche: Synonyms: Anamnesi Osservazione Osservazioni fisiche in dimissione ospedaliera paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | ziekenhuis ontslag lichamelijke bevindingen: |
| ru-RU | Russian (Russian Federation) | Госпитализация выбытие физикальные находки: Synonyms: Выписка Описательный Точка во времени; |
| zh-CN | Chinese (China) | 医院出院体格检查发现: Synonyms: 体格检查（查体、 |
22029-3 Physical exam.total
Term Description
Text area for manual documentation from the history and physical examination about the history of the current tumor and the clinical description of the tumor... NAACCR Data Standards and Data Dictionary Version 11
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Physical exam.total
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Physical exam.total
Basic Attributes
- Class
- TUMRRGT
- Type
- Clinical
- First Released
- Version 1.0n
- Last Updated
- Version 2.63
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 69459-6 | Care record summary panel |
| 49083-9 | North American Association of Central Cancer Registries, Inc (NAACCR, Inc) version 11 panel |
| 59852-4 | North American Association of Central Cancer Registries, Inc (NAACCR, Inc) version 12 panel |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | examen físico.total: |
| es-MX | Spanish (Mexico) | Examen físico total: |
| fr-BE | French (Belgium) | Examen physique.complet: Synonyms: Registre cancer |
| it-IT | Italian (Italy) | Esame obiettivo.totale: Synonyms: Osservazione paziente Punto nel tempo (episodio) Registro tumori |
| nl-NL | Dutch (Netherlands) | lichamelijk onderzoek.volledig: |
| pt-BR | Portuguese (Brazil) | Exame físico.total: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Физикальное исследование.общий: Synonyms: Описательный Точка во времени; |
| zh-CN | Chinese (China) | 体格检查.汇总: Synonyms: NAACCR 肿瘤登记; |
8716-3 Vital signs, physical findings
Term Description
The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Vital signs
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- Observed
Additional Names
- Short Name
- Vital signs
Basic Attributes
- Class
- H&P.PX
- Type
- Clinical
- First Released
- Version 1.0h(3)
- Last Updated
- Version 2.73
- Common Test Rank Get Info
- 576
Member of these Panels
| 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: |
| es-MX | Spanish (Mexico) | Signos vitales: |
| es-AR | Spanish (Argentina) | hallazgos físicos: |
| fr-BE | French (Belgium) | Signes vitaux: |
| it-IT | Italian (Italy) | Segni vitali: Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | vitale functies: |
| pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
| ru-RU | Russian (Russian Federation) | Жизненно важные функции: Synonyms: Описательный Точка во времени; |
| zh-CN | Chinese (China) | 生命体征: Synonyms: 体格检查小节与指标; |
46242-4 Vital signs, fetus
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Vital signs measurements
- Property
- Find
- Time
- Pt
- System
- ^Fetus
- Scale
- Doc
- Method
Additional Names
- Short Name
- Fet Doc Vital signs measurements
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 |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Medidas de constantes vitales: |
| fr-BE | French (Belgium) | Mesure des signes vitaux: |
| it-IT | Italian (Italy) | Parametri vitali, misurazioni: Synonyms: Anamnesi Misurazioni di segni vitali Osservazione Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Avaliação de sinais vitais: Synonyms: Finding; |
| ru-RU | Russian (Russian Federation) | Жизненно важные функции измерения: Synonyms: Документ Точка во времени; |
| zh-CN | Chinese (China) | 生命体征测量结果: Synonyms: 临床文档型; |
11493-4 Hospital discharge studies summary
Observation Required in Panel
Optional
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: |
| es-MX | Spanish (Mexico) | Resumen de estudios de alta hospitalaria: |
| fr-BE | French (Belgium) | Résumé des études de sortie hospitalière: |
| it-IT | Italian (Italy) | Dimissione ospedaliera, sintesi esami: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) Sintesi esami in dimissione ospedaliera |
| nl-NL | Dutch (Netherlands) | ziekenhuis ontslag samenvatting onderzoeken: |
| ru-RU | Russian (Russian Federation) | Госпитализация выбытие исследования краткие сведения: Synonyms: Выписка Описательный Точка во времени; |
| zh-CN | Chinese (China) | 医院出院检查摘要: Synonyms: 允许...离开(医院、 |
30954-2 Relevant diagnostic tests and/or laboratory data
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Relevant diagnostic tests &or laboratory data
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Relevant Dx tests/lab data
Basic Attributes
- Class
- VACCIN
- Type
- Clinical
- First Released
- Version 2.04
- Last Updated
- Version 2.63
- Order vs. Observation
- Observation
Member of these Panels
| 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: |
| es-AR | Spanish (Argentina) | pruebas diagnósticas relevantes y/o información de laboratorio: |
| es-MX | Spanish (Mexico) | Pruebas de diagnóstico o datos de laboratorio relevantes: |
| fr-BE | French (Belgium) | Test de diagnostic utiles et données de laboratoire: |
| it-IT | Italian (Italy) | Test diagnostici rilevanti &o dati di laboratorio: Synonyms: Osservazione paziente Punto nel tempo (episodio) Test diagnostici rilevanti/dati di laboratorio Vaccinazioni |
| nl-NL | Dutch (Netherlands) | relevante diagnostische tests en/of laboratoriumgegevens: |
| pt-BR | Portuguese (Brazil) | Testes diagnósticos relevantes e/ou dados laboratóriais: Synonyms: ; |
| ru-RU | Russian (Russian Federation) | Значимый диагностический тест &или лабораторные данные: Synonyms: Описательный Точка во времени; |
| zh-CN | Chinese (China) | 相关诊断试验和或实验室数据: Synonyms: 医疗服务对象; |
18776-5 Plan of care
Term Description
Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.
Source: Regenstrief LOINC
Observation Required in Panel
Optional
Fully-Specified Name
- Component
- Plan of care note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Plan of care note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.67
- Change Reason
- Previous Releases: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.;
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 57082-0 | Antepartum record panel |
| 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 |
| 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 |
| 81241-2 | Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections |
| 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 |
| 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 |
| 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 |
| 72227-2 | Surgical operation note - recommended C-CDA R1.1 and 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}| |
| LG38745-2 | Plan of care note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-DE | German (Germany) | Behandlungsplan - Notiz: |
| es-AR | Spanish (Argentina) | plan de tratamiento: |
| es-MX | Spanish (Mexico) | Nota del plan de cuidados: |
| it-IT | Italian (Italy) | Piano di cura, nota: Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | behandelplan: Synonyms: zorgplan |
| zh-CN | Chinese (China) | 医疗服务计划记录: Synonyms: 临床文档型; |