48765-2 Allergies

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.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Additional Names

Short Name

Allergies &or adverse reactions Doc

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73

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

8648-8 Hospital course Narrative

Term Description

Hospital course describes the sequence of events from admission to discharge in a hospital facility.
Source: Regenstrief LOINC

Observation Required in Panel

Required

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

Language Variants Get Info

Related Names

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

11535-2 Hospital discharge Dx Narrative

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

Required

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

Language Variants Get Info

Related Names

• Diagnosis
• Disch
• H+P
• H+P.HX
• Hosp
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• Narrative
• P prime
• Point in time
• Random
• Report

10183-2 Hospital discharge medications Narrative

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

Required

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

Language Variants Get Info

Related Names

• Disch
• discharge medication
• Discharge meds
• Finding
• Findings
• H+P
• H+P.HX
• Hosp
• Narrative
• P prime
• Point in time
• Random
• Report

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

Required

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

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

10154-3 Chief complaint Narrative - Reported

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

Language Variants Get Info

Related Names

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

46239-0 Chief complaint+Reason for visit Narrative

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

Language Variants Get Info

Related Names

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

42344-2 Discharge diet (narrative)

Term Description

Discharge diet is a narrative description of the expectations for diet, including proposals, goals, and order requests for monitoring, tracking, or improving the dietary control of the patient, used in a discharge from a facility such as an emergency department, hospital, or nursing home.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Discharge diet

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

Language Variants Get Info

Related Names

• ATTACH
• ATTACH.CLINRPT
• Disch
• Finding
• Findings
• Narrative
• Point in time
• Random
• Report

10157-6 History of family member diseases Narrative

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

Language Variants Get Info

Related Names

• Fam Mem
• Family member diseases Hx
• H/O
• H+P
• H+P.HX
• History
• Hx
• Narrative
• P prime
• Point in time
• Random
• Report

47420-5 Functional status assessment note

Term Description

Functional status assessment describes the patient's status of normal functioning at the time a care record was created. Functional statuses include information regarding the patient relative to ambulatory ability, mental status or competency, activities of daily living (ADLs) (i.e. bathing, dressing, feeding, grooming), home/living situation having an effect on the health status of the patient, ability to care for self, social activity (i.e. issues with social cognition, participation with friends and acquaintances other than family members), occupation activity (i.e. activities partly or directly related to working), housework or volunteering, family and home responsibilities or activities related to home and family, communication ability (i.e. issues with speech, writing or cognition required for communication), and perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Functional status assessment note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Functional status note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.67

Change Reason

Previous Releases: Based on Clinical LOINC Committee approval on 2/17/2012, "note" was added to the Component as the Kind of Document.; 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

• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• Functional status note
• notes
• Point in time
• Random
• Visit note

10164-2 History of Present illness Narrative

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

Language Variants Get Info

Related Names

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

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

Language Variants Get Info

Related Names

• Diagnosis
• H+P
• H+P.HX
• Hosp
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• Narrative
• P prime
• Point in time
• Random
• Report

Related Codes

18841-7 Hospital consultations Document

Observation Required in Panel

Optional

Fully-Specified Name

Component

Hospital consultations

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Additional Names

Short Name

Hospital consultations Doc

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 1.0l

Last Updated

Version 2.67

Change Reason

Release 2.67: PROPERTY: Corrected the Property since this concept represents a collection of information.

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

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

8653-8 Hospital Discharge instructions

Observation Required in Panel

Optional

Fully-Specified Name

Component

Discharge instructions

Property

Find

Time

Pt

System

Hospital

Scale

Doc

Method

{Role}

Additional Names

Short Name

Hosp Discharge instruct

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.67

Change Reason

Updated term to represent the current 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

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Disch
• DOC.ONT
• Document
• Finding
• Findings
• Hosp
• Inpatient
• Point in time
• Random

10184-0 Hospital discharge physical findings Narrative

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

Language Variants Get Info

Related Names

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

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

Language Variants Get Info

Related Names

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

47519-4 History of Procedures Document

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.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

History of procedures

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Procedures Hx Doc

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63

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

11369-6 History of Immunization Narrative

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

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Immunization status
• Narrative
• P prime
• Point in time
• Random
• Report
• Vaccination
• Vaccinations
• Vaccine

11450-4 Problem list - Reported

Observation Required in Panel

Optional

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

Language Variants Get Info

Related Names

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

11493-4 Hospital discharge studies summary Narrative

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

Language Variants Get Info

Related Names

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

29299-5 Reason for visit Narrative

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

Language Variants Get Info

Related Names

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

10187-3 Review of systems Narrative - Reported

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

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 Narrative

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

Language Variants Get Info

Related Names

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

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.
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

Language Variants Get Info

Related Names

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