48765-2 Alerts

Term Description

Contains a list and description of any allergies or adverse reactions pertinent to current or past medical history. At a minimum this section should contain currently active and any relevant historical allergies and adverse reactions.

Observation Required in Panel

Required

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Allergies and adverse reactions Document

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

Change Reason

Previous Releases: Edited Component part from "Allergies, adverse reactions, alerts" to "Allergies &or adverse reactions." We removed the word "alerts" because it was potentially confusing by implying that it may contain other kinds of warnings (as a arbitrary example: public health disease outbreak notifications) when in fact it was always intended to be the typical "allergies" section.;

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• MISC
• Point in time
• Random

51848-0 Assessment

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

Evaluation Note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.73 (MIN)

Change Reason

Previous Releases: 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

Common Test Rank Get Info

6628

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Assessment
• DOC.ONT
• Document
• Encounter
• Eval
• Eval note
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H&P
• History and physical
• notes
• Point in time
• Random
• Visit note

51847-2 Assessment+Plan

Term Description

The Assessment and Plan note (also called impression or diagnoses) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block. The Plan section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education was given or will be provided.

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation+Plan note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

Evaluation + Plan Note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.81 (MIN)

Change Reason

Release 2.81: ValidHL7AttachmentRequest: Updated to add to HIPAA Attachments, per user request.; Previous Releases: Changed 'Assesment' to 'Evaluation' to harmonize existing terms with similar meaning. The term 'Evaluation' will be used in the LOINC Document Ontoloy based on Clinical LOINC Committee decision (Sept 2014).; 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

No IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Assessment
• Assessment+Plan note
• DOC.ONT
• Document
• Encounter
• Eval
• Eval+Plan note
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H&P
• History and physical
• notes
• Point in time
• Random
• Visit note

10154-3 Chief complaint

Term Description

Chief complaint records the patient's primary complaint (the patient's own description).

Observation Required in Panel

Required

Fully-Specified Name

Component

Chief complaint

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Long Common Name

Chief complaint Narrative - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

10157-6 Family history

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

History of family member diseases note

Property

Hx

Time

Pt

System

^Family member

Scale

Doc

Method

Long Common Name

History of family member diseases note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; 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

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Fam Mem
• Family member diseases Hx
• H/O
• H+P
• H+P.HX
• History
• Hx
• Hx of fam member ds note
• notes
• P prime
• Point in time
• Random
• Visit note

10210-3 General status

Term Description

Physical findings (of general status) describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.

Observation Required in Panel

Required

Fully-Specified Name

Component

Physical findings

Property

Find

Time

Pt

System

General status

Scale

Nar

Method

Observed

Long Common Name

Physical findings of General status Narrative

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• Narrative
• P prime
• Phys find
• Point in time
• Random
• Report

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.

Observation Required in Panel

Optional

Fully-Specified Name

Component

Present illness

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Present illness Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Narrative
• P prime
• Point in time
• Pres illness
• Random
• Report

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.

Observation Required in Panel

Optional

Fully-Specified Name

Component

Immunization note

Property

Hx

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

History of Immunization note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; 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

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• H+P
• H+P.HX
• History
• Immunization status
• notes
• P prime
• Point in time
• Random
• Vaccination
• Vaccinations
• Vaccine
• Visit note

69730-0 Instructions

Term Description

The Instructions section records instructions given to a patient. Examples of what it might contain include: instructions about not resuming normal activities, potential complications, use of medications, follow-up with healthcare providers, etc.

Observation Required in Panel

Optional

Fully-Specified Name

Component

Instructions

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.38

Last Updated

Version 2.73 (MIN)

Change Reason

Previous Releases: Updated System, Scale and Property to harmonize with the currently LOINC Document Ontology model.; 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

Common Test Rank Get Info

3636

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• DOC.ONT
• Document
• Finding
• Findings
• Point in time
• Random

10160-0 Medications

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Medication use Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Narrative
• P prime
• Point in time
• Random
• Report

11348-0 Past medical history

Term Description

History of past illness describes the history related to their current complaints, problems, or diagnoses.

Observation Required in Panel

Required

Fully-Specified Name

Component

Past illness note

Property

Hx

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

History of Past illness note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; 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

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• H+P
• H+P.HX
• History
• Last
• notes
• P prime
• Point in time
• Random
• Visit note

29545-1 Physical examination

Observation Required in Panel

Required

Fully-Specified Name

Component

Physical findings note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Long Common Name

Physical findings note

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• notes
• P prime
• Phys find
• Point in time
• Random
• Visit note

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Plan of care note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

Plan of Care Note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 1.0l

Last Updated

Version 2.67 (MIN)

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

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Care plan
• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Treatment plan
• Visit note

11450-4 Problems

Observation Required in Panel

Optional

Fully-Specified Name

Component

Problem list

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Reported

Long Common Name

Problem list - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.73 (MIN)

Common Test Rank Get Info

9889

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Nominal
• P prime
• Point in time
• Random

47519-4 Procedures

Term Description

This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically and at the time the document is generated.

Observation Required in Panel

Optional

Fully-Specified Name

Component

History of procedures

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

History of Procedures Document

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

Change Reason

Previous Releases: 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.;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Finding
• Findings
• H/O
• H+P
• H+P.HX
• Hx
• P prime
• Point in time
• Procedures Hx
• Random

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Reason for visit

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

Reason for visit Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Chief complaint+Reason for visit

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

Chief complaint+Reason for visit Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

30954-2 Results (Diagnostic findings)

Observation Required in Panel

Required

Fully-Specified Name

Component

Relevant diagnostic tests &or laboratory data note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Relevant diagnostic tests/laboratory data note

Basic Attributes

Class

VACCIN

Type

Clinical

First Released

Version 2.04

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Relevant Dx tests/lab data
• Relevant dx tests/lab data note
• VACCINE
• Visit note

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Review of systems

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Long Common Name

Review of systems Narrative - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Social history note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Social history note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H+P
• H+P.HX
• Hx
• notes
• P prime
• Point in time
• Random
• Social Hx
• Social hx note
• Visit note

8716-3 Vital signs

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Vital signs note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Long Common Name

Vital signs note

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Common Test Rank Get Info

576

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H+P
• H+P.PX
• notes
• P prime
• Point in time
• Random
• Visit note