72231-4
Consultation note - recommended C-CDA R1.1 sections
Active
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}| |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Evaluación + nota del plan: |
it-IT | Italian (Italy) | Valutazione+Nota di piano: 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: Synonyms: 临床文档型; |
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}| |
LG38847-6 | Evaluation note| |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Nota de evaluación: |
it-IT | Italian (Italy) | Valutazione, nota: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) Ruolo non specificato |
nl-NL | Dutch (Netherlands) | onderzoeksverslag: Synonyms: evaluatieverslag |
zh-CN | Chinese (China) | 评价记录: Synonyms: 临床文档型; |
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}| |
LG38745-2 | Plan of care note| |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Behandlungsplan - Notiz: |
es-AR | Spanish (Argentina) | plan de tratamiento: |
es-MX | Spanish (Mexico) | Nota del plan de cuidados: |
it-IT | Italian (Italy) | Piano di cura, nota: Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio) Ruolo non specificato |
nl-NL | Dutch (Netherlands) | behandelplan: Synonyms: zorgplan |
zh-CN | Chinese (China) | 医疗服务计划记录: Synonyms: 临床文档型; |
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: |
es-AR | Spanish (Argentina) | antecedentes de la enfermedad actual: |
es-MX | Spanish (Mexico) | Enfermedad presente: |
it-IT | Italian (Italy) | Malattia attuale: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
nl-NL | Dutch (Netherlands) | huidige ziekte: Synonyms: anamnese |
zh-CN | Chinese (China) | 现有疾病: Synonyms: 医疗服务对象; |
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: |
es-MX | Spanish (Mexico) | Hallazgos físicos: |
fr-BE | French (Belgium) | Examen physique: |
it-IT | Italian (Italy) | Osservazioni fisiche: Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | lichamelijke bevindingen: |
pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Физикальные находки: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 体格检查发现: Synonyms: 体格检查(查体、 |
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: Synonyms: Allegato Allegato referto clinico Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | reden voor overplaatsing: |
pt-BR | Portuguese (Brazil) | Motivo do encaminhamento: Synonyms: Finding; |
ru-RU | Russian (Russian Federation) | Причина направления: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 关于转诊的原因: Synonyms: 临床报告信息附件; |
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: |
es-MX | Spanish (Mexico) | Razón de la visita: |
fr-CA | French (Canada) | Raison de visite: |
fr-BE | French (Belgium) | Raison de consultation: |
it-IT | Italian (Italy) | Motivo della visita: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | reden voor bezoek: |
pt-BR | Portuguese (Brazil) | Motivo da visita: Synonyms: Finding; |
ru-RU | Russian (Russian Federation) | Причина визит: Synonyms: Описательный Причина визита Точка во времени; |
zh-CN | Chinese (China) | 关于就诊的原因: Synonyms: 关于就诊的理由; |
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: |
es-MX | Spanish (Mexico) | Alergias y reacciones adversas: |
it-IT | Italian (Italy) | Allergie &o reazioni avverse: Synonyms: Allergie e reazioni avverse Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | allergieën en/of allergische reacties: |
ru-RU | Russian (Russian Federation) | Аллергии &или неблагоприятные реакции: Synonyms: Документ Точка во времени; |
zh-CN | Chinese (China) | 变态反应和或不良反应: Synonyms: 临床文档型; |
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: |
fr-BE | French (Belgium) | Plainte principale+raison de visite: |
it-IT | Italian (Italy) | Disturbo principale+Motivo dell'incontro: 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: |
pt-BR | Portuguese (Brazil) | Reclamação à chefia+Motivo da visita: Synonyms: Finding; |
ru-RU | Russian (Russian Federation) | Основная жалоба+Причина визита: Synonyms: Описательный Причина визита Проблема; |
zh-CN | Chinese (China) | 主诉+就诊原因: Synonyms: 主诉+就诊理由; |
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: |
es-MX | Spanish (Mexico) | Queja principal: |
fr-BE | French (Belgium) | Plainte principale: |
it-IT | Italian (Italy) | Disturbo principale: Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | belangrijkste klacht: |
ru-RU | Russian (Russian Federation) | Основная жалоба: Synonyms: Анамнестические сведения; |
zh-CN | Chinese (China) | 主诉: Synonyms: 医疗服务对象; |
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: |
es-MX | Spanish (Mexico) | Historia de enfermedades de miembros de la familia: |
fr-BE | French (Belgium) | Anamnèse. Maladies dans la famille: |
fr-CA | French (Canada) | Antécédents familiaux: |
it-IT | Italian (Italy) | Storia di malattie di membri familiari: Synonyms: Anamnesi Punto nel tempo (episodio) Storia di malattie di membri della famiglia Storia; |
nl-NL | Dutch (Netherlands) | geschiedenis van ziekte binnen de familie: Synonyms: anamnese ziekte in familieanamnese |
ru-RU | Russian (Russian Federation) | История член семьи заболевания: Synonyms: История Описательный Семейный анамнез заболеваний Точка во времени; |
zh-CN | Chinese (China) | 家族成员疾病史: Synonyms: 历史; |
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: |
es-MX | Spanish (Mexico) | Hallazgos físicos: |
it-IT | Italian (Italy) | Osservazioni fisiche: Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio) |
pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Физикальные находки: Synonyms: Общее состояние Описательный Точка во времени; |
zh-CN | Chinese (China) | 体格检查发现: Synonyms: 体格检查(查体、 |
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: |
es-AR | Spanish (Argentina) | antecedentes de enfermedades pasadas: |
es-MX | Spanish (Mexico) | Enfermedad pasada: |
fr-BE | French (Belgium) | Anamnèse. Maladies antérieures: |
it-IT | Italian (Italy) | Malattie pregresse: Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia; |
nl-NL | Dutch (Netherlands) | ziektegeschiedenis: Synonyms: anamnese |
ru-RU | Russian (Russian Federation) | История предыдущих заболеваний: Synonyms: Анамнез заболеваний История Описательный Точка во времени; |
zh-CN | Chinese (China) | 既往病史: Synonyms: 医疗服务对象; |
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: |
es-AR | Spanish (Argentina) | antecedente de inmunización: |
es-MX | Spanish (Mexico) | Inmunización: |
fr-BE | French (Belgium) | Anamnèse. Immunisations: |
it-IT | Italian (Italy) | Immunizzazioni: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
nl-NL | Dutch (Netherlands) | inenting: Synonyms: anamnese vaccinatie |
ru-RU | Russian (Russian Federation) | История иммунизаций: Synonyms: История Описательный Точка во времени; |
zh-CN | Chinese (China) | 疫苗接种史: Synonyms: 免疫接种历史; |
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: |
es-AR | Spanish (Argentina) | antecedentes de consumo de medicaciones: |
es-MX | Spanish (Mexico) | Uso de medicación: |
fr-BE | French (Belgium) | Anamnèse. Utilsation médications: |
it-IT | Italian (Italy) | Uso di farmaci: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
nl-NL | Dutch (Netherlands) | medicijngebruik: Synonyms: anamnese geneesmiddelen |
ru-RU | Russian (Russian Federation) | История лекарственный препарат употребления: Synonyms: История Лекарственный анамнез Описательный Точка во времени; |
zh-CN | Chinese (China) | 用药史: Synonyms: 医疗服务对象; |
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: |
es-AR | Spanish (Argentina) | lista de problemas: |
es-MX | Spanish (Mexico) | Lista de problemas: |
fr-CA | French (Canada) | Liste des problèmes: |
fr-BE | French (Belgium) | Liste de problèmes: |
it-IT | Italian (Italy) | Lista dei problemi: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | probleemlijst: |
pt-BR | Portuguese (Brazil) | Lista de problemas: Synonyms: Finding; |
ru-RU | Russian (Russian Federation) | Проблем список: Synonyms: Анамнестические сведения; |
zh-CN | Chinese (China) | 问题列表: Synonyms: 分类型应答; |
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: |
es-MX | Spanish (Mexico) | Historia de los procedimientos: |
it-IT | Italian (Italy) | Storia di Procedure: Synonyms: Anamnesi Osservazione Punto nel tempo (episodio) Ruolo non specificato |
nl-NL | Dutch (Netherlands) | voorgeschiedenis met verrichtingen: Synonyms: procedures in anamnese |
pt-BR | Portuguese (Brazil) | Histórico de procedimentos: Synonyms: ; |
zh-CN | Chinese (China) | 操作史: Synonyms: 临床文档型; |
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: |
es-AR | Spanish (Argentina) | pruebas diagnósticas relevantes y/o información de laboratorio: |
es-MX | Spanish (Mexico) | Pruebas de diagnóstico o datos de laboratorio relevantes: |
fr-BE | French (Belgium) | Test de diagnostic utiles et données de laboratoire: |
it-IT | Italian (Italy) | Test diagnostici rilevanti &o dati di laboratorio: Synonyms: Osservazione paziente Punto nel tempo (episodio) Test diagnostici rilevanti/dati di laboratorio Vaccinazioni |
nl-NL | Dutch (Netherlands) | relevante diagnostische tests en/of laboratoriumgegevens: |
pt-BR | Portuguese (Brazil) | Testes diagnósticos relevantes e/ou dados laboratóriais: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Значимый диагностический тест &или лабораторные данные: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 相关诊断试验和或实验室数据: Synonyms: 医疗服务对象; |
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: |
es-MX | Spanish (Mexico) | Revisión de sistemas: |
fr-BE | French (Belgium) | Revue des systèmes: |
it-IT | Italian (Italy) | Esame di apparati: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | beoordeling van systemen: |
ru-RU | Russian (Russian Federation) | Исследование по системам: Synonyms: Анамнестические сведения; |
zh-CN | Chinese (China) | 系统评审: Synonyms: 医疗服务对象; |
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: |
es-AR | Spanish (Argentina) | antecedentes sociales: |
es-MX | Spanish (Mexico) | Historia social: |
fr-BE | French (Belgium) | Histoire sociale: |
it-IT | Italian (Italy) | Storia sociale: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | sociale geschiedenis: |
pt-BR | Portuguese (Brazil) | Histórico social: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Социальная история: Synonyms: Описательный Социальный анамнез Точка во времени; |
zh-CN | Chinese (China) | 社会史: Synonyms: 医疗服务对象; |
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: |
es-MX | Spanish (Mexico) | Signos vitales: |
es-AR | Spanish (Argentina) | hallazgos físicos: |
fr-BE | French (Belgium) | Signes vitaux: |
it-IT | Italian (Italy) | Segni vitali: Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | vitale functies: |
pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Жизненно важные функции: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 生命体征: Synonyms: 体格检查小节与指标; |