Version 2.79

Term Description

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.

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

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

Fully-Specified Name

Component
History and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections
Property
-
Time
Pt
System
{Setting}
Scale
-
Method

Additional Names

Long Common Name
History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
Short Name
H+P C-CDA R1.1+2.0+2.1 Sections

Basic Attributes

Class
PANEL.DOC
Type
Clinical
First Released
Version 2.42
Last Updated
Version 2.56 (NAM)
Change Reason
Changed Component name to reflect that this convenience panel contains recommended sections for C-CDA 1.1, 2.0 and 2.1.
Panel Type
Convenience group

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σημείωμα ιστορικού και φυσικής κατάστασης- συνιστώμενες ενότητες C-CDA R1.1 & R2.0 & R2.1:-:Pt:{Ρυθμίσεις}:-:
Synonyms: C Σημείωμα ιστορικού και φυσικής εξέτασης Σημείωμα ιστορικού και φυσικής κατάστασης- συνιστώμενες ενότητες C-CDA R1.1 & R2.0 & R2.1 Σημείωση
es-MX Spanish (Mexico) Historial y nota física: secciones recomendadas de C-CDA R1.1 y R2.0 y R2.1:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Anamnesi e visita medica - sezioni C-CDA R1.1 e R2.0 e R2.1 raccomandati:-:Pt:{Setting}:-:
Synonyms: Anamnesi e visita medica - sezioni C-CDA R1.1 e R2.0 e Panel documentazione Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) История и физикальное исследование запись - рекомендованные CDA разделы:-:ТчкВрм:{Окружение}:-:
Synonyms: Анамнез и данные медицинского осмотра - рекомендованные CDA разделы Анамнез и физикальное иследование запись Точка во времени;Момент
zh-CN Chinese (China) 病史与体格检查记录 - 推荐 CDA 小节:-:时间点:{环境}:-:
Synonyms: C 型;丙;丙型 事件发生的地方;场景;环境;背景 先天性红细胞生成异常性贫血 先天性红细胞生成异常性贫血（Congenital dyserythropoietic anaemia，CDA） 先天性红细胞生成障碍性贫血 先天性红血球生成不良性贫血 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.文档;文书组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目）;文件医嘱组;医疗文书医嘱组;医疗文件医嘱组 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 病史（历史）与体格检查（查体）记录 - 推荐（建议） CDA 小节（章节、部分）;Consolidated-Clinical Document Architecture;联合临床文档架构;统一临床文档架构;C-CDA;HL7 临床文档架构;HL7 Clinical Document Architecture;HL7 CDA 笔记;按语;注释;说明;票据;单据;证明书 组 组合 组合医嘱 组合类 组套

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=72228-0
Questionnaire definition
https://fhir.loinc.org/Questionnaire/?url=http://loinc.org/q/72228-0