LOINC
Version 2.71

78508-9Cardiothoracic surgery Admission history and physical noteActive

Fully-Specified Name

Component
Admission history and physical note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Thoracic and cardiac surgery

Additional Names

Short Name
Cardiothor surg 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
Change Reason
Based on Clinical LOINC Committee review (1/2016), changed Method from "Thoracic surgery" to more precisely convey the meaning of this term.
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38752-8 Admission history and physical note|ANYRole|ANYSetting
LG38997-9 Thoracic and cardiac surgery|ANYTypeOfService|ANYKindOfNote|ANYSetting

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:胸心外科学
fr-BEFrench (Belgium)
Note d'admission. Anamnèse et examen physique:Observation:Temps ponctuel:{réglages}:Document:Chirurgie thoracique
it-ITItalian (Italy)
Ricovero, anamnesi e visita medica:Osservazione:Pt:{Setting}:Doc:Chirurgia toracica

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=78508-9