Version 2.77

Status Information

Status
DISCOURAGED
Comment
The current best practice is to map to the more specific note (i.e. corresponding Obstetric note or Gynecology note) where it is possible.
Map-To Long Common Name Mapping Guidance
89215-8 Gynecology Admission history and physical note
89443-6 Obstetrics Admission history and physical note

Fully-Specified Name

Component
Admission history and physical note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Obstetrics and Gynecology

Additional Names

Short Name
OBGYN Admit H&P note

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 2.64
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38752-8 Admission history and physical note|ANYRole|ANYSetting
LG38968-0 Obstetrics and Gynecology|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Historial de admisión y nota física:Tipo:Punto temporal:{Configuración}:Documento:Obstetrics and Gynecology
fr-BE French (Belgium) Note d'admission. Anamnèse et examen physique:Observation:Temps ponctuel:{réglages}:Document:Obstétrique et Gynécologie
it-IT Italian (Italy) Ricovero, anamnesi e visita medica:Osservazione:Pt:{Setting}:Doc:Ostetricia e Ginecologia
Synonyms: Documentazione dell''ontologia Erogazione prescrizione di ricovero: accettazione; Osservazione Punto nel tempo (episodio)
zh-CN Chinese (China) 入院史与体格检查记录:发现:时间点:{环境}:文档型:产科学与妇科学
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 产科与妇科;妇产科;妇产科学;妇产;女科 产科学方法;产科方法;产科法;产科;助产术 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 妇人科;妇科;妇科医学 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 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=78718-4