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LOINC Names Get Info

Fully-Specified Name
Admission history and physical note:Find:Pt:Emergency department:Doc:{Role}
Long Common Name
Emergency Department Admission History and Physical Note
Short Name
ED Admit H&P Note

Part Model Get Info

  • Component
    Admission history and physical note
    LP57379-7
    • Analyte
      Admission history and physical note
      LP57379-7
      • Component Numerator
        Admission history and physical note
        LP57379-7
        • Component Numerator Core
          Admission history and physical note
          LP57379-7
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Find
    LP6813-2
  • Time
    Pt
    LP6960-1
  • System
    Emergency department
    LP66706-0
    • System Core
      Emergency department
      LP66706-0
    • Super System
      NULL
       
  • Scale
    Doc
    LP32888-7
  • Method
    {Role}
    LP187178-1

Associated Observations

72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

This panel contains the recommended sections for history and physical notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.

LOINCNameR/O/CCardinalityExample UCUM Units
72228-0History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
Indent48765-2AlertsR
Indent51848-0AssessmentR
Indent51847-2Assessment+PlanR
Indent10154-3Chief complaintR
Indent10157-6Family historyR
Indent10210-3General statusR
Indent10164-2History of present illnessO
Indent11369-6History of immunizationsO
Indent69730-0InstructionsO
Indent10160-0MedicationsR
Indent11348-0Past medical historyR
Indent29545-1Physical examinationR
Indent18776-5Plan of careR
Indent11450-4ProblemsO
Indent47519-4ProceduresO
Indent29299-5Reason for visitR
Indent46239-0Reason for visit and Chief complaintR
Indent30954-2Results (Diagnostic findings)R
Indent10187-3Review of systemsR
Indent29762-2Social historyR
Indent8716-3Vital signsR

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.54
Last Updated
Version 2.58 (MIN)
Change Reason
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
Implementation guide exists

Member of these Groups Get Info

LOINC GroupGroup Name
LG38752-8Admission history and physical note|ANYRole|ANYSetting
LG41825-7Emergency department|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Ιστορικό και φυσική κατάσταση εισαγωγής:Εύρεση:Pt:Τμήμα επειγόντων περιστατικών:Doc:{Ρόλος}
Synonyms: {Ρόλος} Doc DOC.ONTOLOGY Pt Εύρεση Ιστορικό και φυσική κατάσταση εισαγωγής Σημείωμα ιστορικού και φυσικής εξέτασης Σημείωση Τμήμα επειγόντων περιστατικών
es-MXSpanish (Mexico)Historial de admisión y nota física:Tipo:Punto temporal:Departamento de Emergencia:Documento:{Role}
it-ITItalian (Italy)Ricovero, anamnesi e visita medica:Osservazione:Pt:Pronto Soccorso:Doc:{Role}
Synonyms: Documentazione dell''ontologia Erogazione prescrizione di ricovero: accettazione Osservazione Punto nel tempo (episodio) Ruolo non specificato
zh-CNChinese (China)入院史与体格检查记录:发现:时间点:急诊科: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 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 急诊;急诊部门;急诊部;急诊室;急症科;急诊科室;急救部门 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

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=78249-0