LOINC
Version 2.71

78718-4Obstetrics and Gynecology Admission history and physical noteDiscouraged

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

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

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

zh-CNChinese (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
fr-BEFrench (Belgium)
Note d'admission. Anamnèse et examen physique:Observation:Temps ponctuel:{réglages}:Document:Obstétrique et Gynécologie
it-ITItalian (Italy)
Ricovero, anamnesi e visita medica:Osservazione:Pt:{Setting}:Doc:Ostetricia e Ginecologia

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=78718-4