Version 2.78

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.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Evaluation+Plan note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Eval+Plan note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.63
Change Reason
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

Member of these Panels

LOINC Long Common Name
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Evaluación + nota del plan:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Valutazione+Nota di piano:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato Valutazione + Nota di piano
zh-CN Chinese (China) 评价+计划记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书 评价(评估、测评、评测、评判、评定、判定、评量、核定)+计划记录;评估+计划记录;评估与计划记录 评估 评定 鉴定

51848-0 Assessment

Observation Required in Panel

Required

Fully-Specified Name

Component
Evaluation note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Eval note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.73
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

LOINC Long Common Name
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
82811-1 Nurse summary note - recommended sections
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38847-6 Evaluation note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de evaluación:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Valutazione, nota:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) onderzoeksverslag:bevinding:moment:{instelling}:document:{rol}
Synonyms: evaluatieverslag
zh-CN Chinese (China) 评价记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书 评价(评估、测评、评测、评判、评定、判定、评量、核定)记录;评估记录 评估 评定 鉴定

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

LOINC Long Common Name
57082-0 Antepartum record panel
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
82811-1 Nurse summary note - recommended sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38745-2 Plan of care note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Behandlungsplan - Notiz:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-AR Spanish (Argentina) plan de tratamiento:hallazgo:punto en el tiempo:plan de tratamiento:Narrativo:
es-MX Spanish (Mexico) Nota del plan de cuidados:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) behandelplan:bevinding:moment:{instelling}:document:{rol}
Synonyms: zorgplan
zh-CN Chinese (China) 医疗服务计划记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 医疗服务(照护服务、护理服务、护理、照护、医疗照护、诊疗、诊疗服务、照顾、看护)计划(方案)记录 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书

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.
Source: Regenstrief LOINC

Observation Required in Panel

Required

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese der aktuellen Krankheit:Anamnese:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad presente:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Malattia attuale:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) huidige ziekte:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
zh-CN Chinese (China) 现有疾病:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 现病史;目前疾病;当前疾病;现病 病史与体格检查

29545-1 Physical examination

Observation Required in Panel

Required

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observado
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
fr-BE French (Belgium) Examen physique:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:^Paciente:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 观测法

42349-1 Reason for referral

Observation Required in Panel

Required

Fully-Specified Name

Component
Reason for referral
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 2.73
Common Test Rank Get Info
2371

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Zuweisungsdiagnose
it-IT Italian (Italy) Motivo per rinvio:Osservazione:Pt:^Paziente:Nar:
Synonyms: Allegato Allegato referto clinico Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) reden voor overplaatsing:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Motivo do encaminhamento:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Причина направления:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 关于转诊的原因:发现:时间点:^患者:叙述型:
Synonyms: 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 关于转诊(转诊介绍、转介、送交、转送、转诊介绍信)的原因(理由、缘由);关于转诊的理由;关于转诊介绍的原因;关于转诊介绍信的原因 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间

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.
Source: Regenstrief LOINC

Observation Required in Panel

Required

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) motivo de la consulta:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Razón de la visita:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-CA French (Canada) Raison de visite:Observation:Temps ponctuel:^Patient:Narratif:
fr-BE French (Belgium) Raison de consultation:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Motivo della visita:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) reden voor bezoek:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Motivo da visita:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Причина визит:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Причина визита Точка во времени;Момент
zh-CN Chinese (China) 关于就诊的原因:发现:时间点:^患者:叙述型:
Synonyms: 关于就诊的理由;关于就诊(就医、访视)的原因;就诊原因;就诊理由;就医原因;访视原因;就医理由;访视理由 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查

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

Optional

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

LOINC Long Common Name
57082-0 Antepartum record panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
82811-1 Nurse summary note - recommended sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Allergien und unerwünschte Wirkungen:Befund:Zeitpunkt:^Patient:Dokument:
es-MX Spanish (Mexico) Alergias y reacciones adversas:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Allergie &o reazioni avverse:Osservazione:Pt:^Paziente:Doc:
Synonyms: Allergie e reazioni avverse Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) allergieën en/of allergische reacties:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Аллергии &или неблагоприятные реакции:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 变态反应和或不良反应:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 变态反应与不良反应 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 过敏反应;过敏

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

LOINC Long Common Name
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Queja principal + Motivo de la visita:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Plainte principale+raison de visite:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Disturbo principale+Motivo dell'incontro:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Disturbo primario Disturbo primario e Motivo dell''incontro Lamenta Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) belangrijkste klacht + reden voor bezoek:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Reclamação à chefia+Motivo da visita:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Основная жалоба+Причина визита:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Причина визита Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 主诉+就诊原因:发现:时间点:^患者:叙述型:
Synonyms: 主诉+就诊理由;主诉+就医原因;主诉+访视原因 关于就诊的理由;关于就诊(就医、访视)的原因;就诊原因;就诊理由;就医原因;访视原因;就医理由;访视理由 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 控诉;申诉;指控;不平;牢骚;委屈;意见;怨言;病痛;主诉 时刻;随机;随意;瞬间 病史与体格检查

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
82811-1 Nurse summary note - recommended sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) motivo de consulta principal:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Queja principal:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Plainte principale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Disturbo principale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) belangrijkste klacht:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Основная жалоба:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 主诉:发现:时间点:^患者:叙述型:报告法
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 控诉;申诉;指控;不平;牢骚;委屈;意见;怨言;病痛;主诉 时刻;随机;随意;瞬间 病史与体格检查

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.
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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
35089-2 History and physical panel
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
35090-0 Patient history
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) antecedentes de enfermedades en miembros familiares:hallazgo:punto en el tiempo:familia:Narrativo:informado
es-MX Spanish (Mexico) Historia de enfermedades de miembros de la familia:Hx:Punto temporal:^ Miembro de la familia:Narrativo:
fr-BE French (Belgium) Anamnèse. Maladies dans la famille:Hx:Temps ponctuel:^membre de famille:Narratif:
fr-CA French (Canada) Antécédents familiaux:Histoire:Temps ponctuel:^membre de famille:Narratif:
it-IT Italian (Italy) Storia di malattie di membri familiari:Hx:Pt:^membro della famiglia:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Storia di malattie di membri della famiglia Storia;Anamnesi
nl-NL Dutch (Netherlands) geschiedenis van ziekte binnen de familie:voorgeschiedenis:moment:^familielid:tekstueel:
Synonyms: anamnese ziekte in familieanamnese
ru-RU Russian (Russian Federation) История член семьи заболевания:Hx:ТчкВрм:^семьи член:Опис:
Synonyms: История Описательный Семейный анамнез заболеваний Точка во времени;Момент
zh-CN Chinese (China) 家族成员疾病史:历史记录:时间点:^家庭成员:叙述型:
Synonyms: 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 家人;家族成员;超系统 - 家庭成员 家庭 家族成员病史;家属疾病史;家属病史;家庭成员疾病史;家庭成员病史 时刻;随机;随意;瞬间 病史与体格检查

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.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
General status
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find General status

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:estado general:Narrativo:observado
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:Estatus general:Narrativo:Observed
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:Stato generale:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Estado geral:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:Общий статус:Опис:Наблюдённый
Synonyms: Общее состояние Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:一般状态:叙述型:观察法
Synonyms: 体格检查(查体、体检、身体检查、肉体检查)发现(所见);查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 大体状态;普通状态;总体状态 时刻;随机;随意;瞬间 病史与体格检查 观测法

11348-0 Past medical history

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese früherer Krankheiten:Anamnese:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedentes de enfermedades pasadas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad pasada:Hx:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Anamnèse. Maladies antérieures:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Malattie pregresse:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) ziektegeschiedenis:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История предыдущих заболеваний:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез заболеваний История Описательный Точка во времени;Момент
zh-CN Chinese (China) 既往病史:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 既往疾病史;既往疾病历史 时刻;随机;随意;瞬间 病史与体格检查

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.
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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Immunisierungsstatus
de-DE German (Germany) Impfanamnese:Anamnese:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedente de inmunización:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Inmunización:Hx:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Anamnèse. Immunisations:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Immunizzazioni:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) inenting:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese vaccinatie
ru-RU Russian (Russian Federation) История иммунизаций:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Точка во времени;Момент
zh-CN Chinese (China) 疫苗接种史:历史记录:时间点:^患者:叙述型:
Synonyms: 免疫接种历史;免疫史;接种史;免疫接种史 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查

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.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Medication use
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Medication use

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Medikationsanamnese:Anamnese:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedentes de consumo de medicaciones:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Uso de medicación:Hx:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Anamnèse. Utilsation médications:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Uso di farmaci:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) medicijngebruik:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese geneesmiddelen
ru-RU Russian (Russian Federation) История лекарственный препарат употребления:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Лекарственный анамнез Описательный Точка во времени;Момент
zh-CN Chinese (China) 用药史:历史记录:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 时刻;随机;随意;瞬间 病史与体格检查 药物使用历史;药物使用史

11450-4 Problems

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

LOINC Long Common Name
57082-0 Antepartum record panel
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
82811-1 Nurse summary note - recommended sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
74449-0 Patient plan of care - recommended IHE set
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Problemliste:Befund:Zeitpunkt:^Patient:Nominal:Berichtet
es-AR Spanish (Argentina) lista de problemas:hallazgo:punto en el tiempo:^paciente:Nominal:informado
es-MX Spanish (Mexico) Lista de problemas:Tipo:Punto temporal:^ Paciente:Nominal:Reported
fr-CA French (Canada) Liste des problèmes:Observation:Temps ponctuel:^Patient:Nominal:Rapporté
fr-BE French (Belgium) Liste de problèmes:Observation:Temps ponctuel:^Patient:Nominal:Rapporté
it-IT Italian (Italy) Lista dei problemi:Osservazione:Pt:^Paziente:Nom:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) probleemlijst:bevinding:moment:^patiënt:nominaal:rapportage
pt-BR Portuguese (Brazil) Lista de problemas:Achado:Pt:^Paciente:Nom:Relatado
Synonyms: Finding; Findings; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Проблем список:Находка:ТчкВрм:^Пациент:Ном:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Номинальный;Именной Список проблем Точка во времени;Момент
zh-CN Chinese (China) 问题列表:发现:时间点:^患者:名义型:报告法
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 时刻;随机;随意;瞬间 病史与体格检查 问题目录;问题清单 难题;困难;棘手问题;麻烦;乱子;疑难问题;疑难

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.
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

LOINC Long Common Name
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
82811-1 Nurse summary note - recommended sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese der Prozeduren oder Maßnahmen:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-MX Spanish (Mexico) Historia de los procedimientos:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Storia di Procedure:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Anamnesi Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) voorgeschiedenis met verrichtingen:bevinding:moment:{instelling}:document:{rol}
Synonyms: procedures in anamnese
pt-BR Portuguese (Brazil) Histórico de procedimentos:Achado:Pt:{Fixação}:Doc:{Fornecedor}
Synonyms: ; Procedures Hx; Finding; Findings; Point in time; Random
zh-CN Chinese (China) 操作史:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 操作历史;操作项目历史;操作项目史 时刻;随机;随意;瞬间 未加明确说明的角色 病史与体格检查

30954-2 Results (Diagnostic findings)

Observation Required in Panel

Optional

Fully-Specified Name

Component
Relevant diagnostic tests &or laboratory data
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Relevant Dx tests/lab data

Basic Attributes

Class
VACCIN
Type
Clinical
First Released
Version 2.04
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
82811-1 Nurse summary note - recommended sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
102087-4 Secretin stimulation/Gastrin XXX challenge panel
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Relevante diagnostische Tests &oder Labordaten:Befund:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) pruebas diagnósticas relevantes y/o información de laboratorio:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Pruebas de diagnóstico o datos de laboratorio relevantes:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Test de diagnostic utiles et données de laboratoire:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Test diagnostici rilevanti &o dati di laboratorio:Osservazione:Pt:^Paziente:Nar:
Synonyms: Osservazione paziente Punto nel tempo (episodio) Test diagnostici rilevanti/dati di laboratorio Vaccinazioni
nl-NL Dutch (Netherlands) relevante diagnostische tests en/of laboratoriumgegevens:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Testes diagnósticos relevantes e/ou dados laboratóriais:Achado:Pt:^Paciente:Nar:
Synonyms: ; Relevant Dx tests/lAc data; Finding; Findings; Point in time; Random; Narrative; Report; VACCINE
ru-RU Russian (Russian Federation) Значимый диагностический тест &или лабораторные данные:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 相关诊断试验和或实验室数据:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 接种;接种记录;疫苗;疫苗接种 时刻;随机;随意;瞬间 检验科;化验室;化验科 相关诊断试验/实验室数据;相关诊断试验和或实验室资料;相关诊断试验和或实验室检验数据;相关诊断试验和或检验数据;相关诊断试验和或化验数据

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.
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

LOINC Long Common Name
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) revisión de sistemas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Revisión de sistemas:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Revue des systèmes:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Esame di apparati:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) beoordeling van systemen:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Исследование по системам:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Точка во времени;Момент
zh-CN Chinese (China) 系统评审:发现:时间点:^患者:叙述型:报告法
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 系统回顾;系统审核

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.
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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Sozialanamnese:Befund:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedentes sociales:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Historia social:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Histoire sociale:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Storia sociale:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) sociale geschiedenis:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Histórico social:Achado:Pt:^Paciente:Nar:
Synonyms: ; Social Hx; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Социальная история:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Социальный анамнез Точка во времени;Момент
zh-CN Chinese (China) 社会史:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 社会历史

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

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
82811-1 Nurse summary note - recommended sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Vitalparameter:Befund:Zeitpunkt:^Patient:Freitext:Beobachtet
es-MX Spanish (Mexico) Signos vitales:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:signos vitales:Narrativo:observado
fr-BE French (Belgium) Signes vitaux:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Segni vitali:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) vitale functies:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Sinais vitais:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Жизненно важные функции:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 生命体征:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 生命体征类;生命征象 病史与体格检查 观测法