Version 2.78

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.
Source: Regenstrief LOINC

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

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
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
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