48765-2 Allergies and other adverse reactions

Term Description

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

Observation Required in Panel

Required

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Allergies and adverse reactions Document

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

Change Reason

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

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

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

29545-1 Physical examination

Observation Required in Panel

Conditional

Fully-Specified Name

Component

Physical findings note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Long Common Name

Physical findings note

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

51848-0 Assessment

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

Evaluation Note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.73 (MIN)

Change Reason

Previous Releases: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;

Order vs. Observation

Both

Common Test Rank Get Info

6628

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

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

10187-3 Review of systems Narrative - Reported

Term Description

The Review of systems section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.

Observation Required in Panel

Conditional

Fully-Specified Name

Component

Review of systems

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

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

11450-4 Active problems

Observation Required in Panel

Required

Fully-Specified Name

Component

Problem list

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Reported

Long Common Name

Problem list - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.73 (MIN)

Common Test Rank Get Info

9889

Member of these Panels

Language Variants Get Info

Related Names

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

47420-5 Functional status

Term Description

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

Observation Required in Panel

Conditional

Fully-Specified Name

Component

Functional status assessment note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

Functional Status Assessment Note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.67 (MIN)

Change Reason

Previous Releases: Based on Clinical LOINC Committee approval on 2/17/2012, "note" was added to the Component as the Kind of Document.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;

Order vs. Observation

Both

HL7^® Attachment Structure

No IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

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

10157-6 Family history

Term Description

History of family member diseases is a report of health information, including medical, genetic, environmental, and lifestyle factors, pertaining to the patient and his or her genetic relatives (living or deceased). The family history information is used to determine possible or relevant health risk factors that may have a potential impact on the patient's healthcare risk profile.

Observation Required in Panel

Optional

Fully-Specified Name

Component

History of family member diseases note

Property

Hx

Time

Pt

System

^Family member

Scale

Doc

Method

Long Common Name

History of family member diseases note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; Previous Releases: Changed Property from "Find" to "Hx", removed Method of "Reported" and corrected System from Family to ^Family member to align with existing family history terms and to represent family member as a Super System per 8/2015 Clinical LOINC Committee decision;

Common Test Rank Get Info

9825

Member of these Panels

Language Variants Get Info

Related Names

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

29762-2 Social history note

Term Description

The Social history section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.

Observation Required in Panel

Optional

Fully-Specified Name

Component

Social history note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

42348-3 Advance Healthcare Directives

Term Description

Advance directives contains data defining the patient's direction of care and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. Advance directives contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status.

Observation Required in Panel

Required

Fully-Specified Name

Component

Advance healthcare directives

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.16

Last Updated

Version 2.79 (NAM)

Change Reason

Release 2.79: COMPONENT: Adding the descriptor "healthcare" better reflects its intended use in healthcare contexts, updating the term to "Advance healthcare directives." This modification aims to encompass a broader range of healthcare-specific advance directives; Previous Releases: Based on Clinical LOINC Committee review at the Feb. 2016 meeting, this term represents a document containing information on a patient's advance directives and any supporting documentation, such as a living will. The term was revised to fit the current LOINC Document Ontology model.;

Order vs. Observation

Both

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Adv healthcare directives
• Advanced
• DOC.ONT
• Document
• Finding
• Findings
• Point in time
• Random

18610-6 Medications administered

Observation Required in Panel

Conditional

Fully-Specified Name

Component

Medication.administered

Property

Cmplx

Time

Pt

System

^Patient

Scale

Set

Method

Long Common Name

Medication administered Set

Basic Attributes

Class

ATTACH.MEDS

Type

Claims Attachments

First Released

Version 1.0l

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

• ATTACH
• ATTACH.MEDS
• Complex
• Medication administered
• MEDS
• Point in time
• Random

8975-5 Fluids administered

Part Descriptions

LP76218-4   Fluid intake.intravascular
Intravascular fluid intake refers to fluids administered within the vascular system. This is commonly occurs within a vein (intravenously). There are several types of intravascular fluid that can be administered (eg. liquid food, electrolytes, medications and dyes for radiologic examination). http://www.utas.edu.au/__data/assets/pdf_file/0020/528041/Management-of-IV-Fluids-and-Electrolyte-Balance-slides.pdf Source: Regenstrief LOINC

Observation Required in Panel

Conditional

Fully-Specified Name

Component

Fluid intake.intravascular

Property

Vol

Time

Pt

System

Vascular system

Scale

Qn

Method

Measured

Long Common Name

Fluid intake intravascular Measured

Basic Attributes

Class

IO_IN.MOLEC

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

• BP
• Fld
• Fluid intake IV
• Intravenous
• IO_INTAKE
• IO_INTAKE.MOLEC
• IV
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Volume

Example Units

11348-0 History of Past illness note

Term Description

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

Observation Required in Panel

Conditional

Fully-Specified Name

Component

Past illness note

Property

Hx

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

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

47519-4 Procedures and interventions

Term Description

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

Observation Required in Panel

Conditional

Fully-Specified Name

Component

History of procedures

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Long Common Name

History of Procedures Document

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

Change Reason

Previous Releases: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;

Member of these Panels

Language Variants Get Info

Related Names

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

46209-3 Provider orders

Observation Required in Panel

Required

Fully-Specified Name

Component

Provider orders

Property

Find

Time

-

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.17

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• MISC