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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

LOINCNameR/O/CCardinalityExample UCUM Units
72228-0History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
Indent48765-2AlertsR
Indent51848-0AssessmentR
Indent51847-2Assessment+PlanR
Indent10154-3Chief complaintR
Indent10157-6Family historyR
Indent10210-3General statusR
Indent10164-2History of present illnessO
Indent11369-6History of immunizationsO
Indent69730-0InstructionsO
Indent10160-0MedicationsR
Indent11348-0Past medical historyR
Indent29545-1Physical examinationR
Indent18776-5Plan of careR
Indent11450-4ProblemsO
Indent47519-4ProceduresO
Indent29299-5Reason for visitR
Indent46239-0Reason for visit and Chief complaintR
Indent30954-2Results (Diagnostic findings)R
Indent10187-3Review of systemsR
Indent29762-2Social historyR
Indent8716-3Vital signsR

LOINC Names Get Info

Fully-Specified Name
History and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections:-:Pt:{Setting}:-:
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

Part Model Get Info

  • Component
    History and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections
    LP157177-9
    • Analyte
      History and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections
      LP157177-9
      • Component Numerator
        History and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections
        LP157177-9
        • Component Numerator Core
          History and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections
          LP157177-9
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    -
    LP6769-6
  • Time
    Pt
    LP6960-1
  • System
    {Setting}
    LP32887-9
    • System Core
      {Setting}
      LP32887-9
    • Super System
      NULL
       
  • Scale
    -
    LP7747-1
  • Method
    NULL
     

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

TagLanguageTranslation
el-GRGreek (Greece)Σημείωμα ιστορικού και φυσικής κατάστασης- συνιστώμενες ενότητες C-CDA R1.1 & R2.0 & R2.1:-:Pt:{Ρυθμίσεις}:-:
Synonyms: - {Ρυθμίσεις} C PANEL.DOC Pt Σημείωμα ιστορικού και φυσικής εξέτασης Σημείωμα ιστορικού και φυσικής κατάστασης- συνιστώμενες ενότητες C-CDA R1.1 & R2.0 & R2.1 Σημείωση
es-MXSpanish (Mexico)Historial y nota física: secciones recomendadas de C-CDA R1.1 y R2.0 y R2.1:-:Punto temporal:{Configuración}:-:
it-ITItalian (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-RURussian (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-CNChinese (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