78538-6
Palliative Care Admission History and Physical Note
Active
Part Description
LP200115-6 Palliative care
Palliative care is comfort care that provides relief from physical and mental symptoms of a illness, terminal or not. Palliative care can be pursued at diagnosis, during stages of illness, treatment, follow-up and end of life.
Source: LOINC
LOINC Names Get Info
- Fully-Specified Name
- Admission history and physical note:
Find: Pt: {Setting}: Doc: Palliative care - Long Common Name
- Palliative Care Admission History and Physical Note
- Short Name
- Palliative Care Admit H&P Note
Part Model Get Info
- Component
- Admission history and physical note
LP57379-7
- Analyte
- Admission history and physical note
LP57379-7
- Challenge
- NULL
- Adjustment
- NULL
- Count
- NULL
- Property
- Find
LP6813-2
- Time
- Pt
LP6960-1
- Time Core
- Pt
LP6960-1
- Time Modifier
- NULL
- System
- {Setting}
LP32887-9
- System Core
- {Setting}
LP32887-9
- Super System
- NULL
- Scale
- Doc
LP32888-7
- Method
- Palliative care
LP200115-6
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.
| 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 (MIN)
- Order vs. Observation
- Both
- HL7® Attachment Structure
- Implementation guide exists
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38752-8 | Admission history and physical note| |
| LG39084-5 | Palliative care| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| el-GR | Greek (Greece) | Ιστορικό και φυσική κατάσταση εισαγωγής: Synonyms: {Ρυθμίσεις} Doc DOC.ONTOLOGY Pt Ανακουφιστική φροντίδα Εύρεση Ιστορικό και φυσική κατάσταση εισαγωγής Σημείωμα ιστορικού και φυσικής εξέτασης Σημείωση |
| es-MX | Spanish (Mexico) | Historial de admisión y nota física: |
| it-IT | Italian (Italy) | Ricovero, anamnesi e visita medica: Synonyms: Documentazione dell''ontologia Erogazione prescrizione di ricovero: |
| zh-CN | Chinese (China) | 入院史与体格检查记录: Synonyms: CARE Survey; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
LOINC Copyright
Copyright © Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://