Version 2.76

Term Description

This panel contains the recommended sections for consultation notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.
Source: Regenstrief LOINC

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
72231-4 Consultation note - recommended C-CDA R1.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent10164-2 History of present illness R
Indent29545-1 Physical examination R
Indent42349-1 Reason for referral R
Indent29299-5 Reason for visit R
Indent48765-2 Allergies O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent10157-6 Family history O
Indent10210-3 General status O
Indent11348-0 Past medical history O
Indent11369-6 History of immunizations O
Indent10160-0 Medications O
Indent11450-4 Problems O
Indent47519-4 Procedures O
Indent30954-2 Results (Diagnostic findings) O
Indent10187-3 Review of systems O
Indent29762-2 Social history O
Indent8716-3 Vital signs O

Fully-Specified Name

Consultation note - recommended C-CDA R1.1 sections

Additional Names

Short Name
Consult note C-CDA R1.1 sections

Basic Attributes

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.
Panel Type
Convenience group

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de consulta: secciones recomendadas de C-CDA R1.1:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Nota di consulto - sezioni C-CDA R1.1 raccomandate:-:Pt:{Setting}:-:
Synonyms: Nota di consulto - sezioni C-CDA R1.1 consigliate Panel documentazione Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Консультация запись - рекомендованные CDA разделы:-:ТчкВрм:{Окружение}:-:
Synonyms: Точка во времени;Момент
zh-CN Chinese (China) 会诊记录 - 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 会诊(咨询、会诊咨询、磋商、商讨会)记录 会诊(咨询、会诊咨询、磋商、商讨会)记录 - 推荐(建议) CDA 小节(章节、部分);会诊记录 - 建议 CDA 小节;咨询记录 - 推荐 CDA 小节;HL7 临床文档架构;HL7 Clinical Document Architecture;HL7 CDA 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 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

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