78388-6Neurological surgery Admission history and physical noteActive
Fully-Specified Name
- Component
- Admission history and physical note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Neurological surgery
Additional Names
- Short Name
- Neuro surgery Admit H&P note
Associated Observations
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.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections | |||
| Indent48765-2 | Alerts | R | ||
| Indent51848-0 | Assessment | R | ||
| Indent51847-2 | Assessment+Plan | R | ||
| Indent10154-3 | Chief complaint | R | ||
| Indent10157-6 | Family history | R | ||
| Indent10210-3 | General status | R | ||
| Indent10164-2 | History of present illness | O | ||
| Indent11369-6 | History of immunizations | O | ||
| Indent69730-0 | Instructions | O | ||
| Indent10160-0 | Medications | R | ||
| Indent11348-0 | Past medical history | R | ||
| Indent29545-1 | Physical examination | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent11450-4 | Problems | O | ||
| Indent47519-4 | Procedures | O | ||
| Indent29299-5 | Reason for visit | R | ||
| Indent46239-0 | Reason for visit and Chief complaint | R | ||
| Indent30954-2 | Results (Diagnostic findings) | R | ||
| Indent10187-3 | Review of systems | R | ||
| Indent29762-2 | Social history | R | ||
| Indent8716-3 | Vital signs | R |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.54
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7 Attachment Structure
- Implementation guide exists
Member of these Groups
| LG41826-5 | {Setting}| |
| LG38752-8 | Admission history and physical note| |
| LG38977-1 | Neurological surgery| |
Language Variants Get Info
- zh-CNChinese (China)
- 入院史与体格检查记录:
发现: 时间点: {环境}: 文档型: 神经外科学 - fr-BEFrench (Belgium)
- Note d'admission. Anamnèse et examen physique:
Observation: Temps ponctuel: {réglages}: Document: Chirurgie neurologique - it-ITItalian (Italy)
- Ricovero, anamnesi e visita medica:
Osservazione: Pt: {Setting}: Doc: Chirurgia neurologica
LOINC FHIR® API Example - CodeSystem Request Get Info
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=78388-6
LOINC Copyright
Copyright © 2021 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright