Version 2.78

Term Description

This panel contains the recommended sections for progress notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.
Source: Regenstrief LOINC

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent48765-2 Allergies O
Indent10154-3 Chief complaint Narrative - Reported O
Indent69730-0 Instructions O
Indent62387-6 Interventions Narrative O
Indent10160-0 History of Medication use Narrative O
Indent61144-2 Diet and nutrition Narrative O
Indent61149-1 Objective Narrative O
Indent29545-1 Physical findings Narrative O
Indent11450-4 Problem list - Reported O
Indent30954-2 Results O
Indent10187-3 Review of systems Narrative - Reported O
Indent61150-9 Subjective Narrative O
Indent8716-3 Vital signs O

Fully-Specified Name

Component
Progress note - recommended C-CDA R2.0 & R2.1 sections
Property
-
Time
Pt
System
{Setting}
Scale
-
Method

Additional Names

Short Name
Prog note C-CDA R2.0+2.1 Sections

Basic Attributes

Class
PANEL.DOC
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.56
Panel Type
Convenience group

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de progreso: secciones recomendadas de C-CDA R2.0 y R2.1:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Progresso, nota- sezioni C-CDA R2.0 & R2.1 raccomandate:-:Pt:{Setting}:-:
Synonyms: Nota di progresso;Nota di miglioramento Panel documentazione Punto nel tempo (episodio)
zh-CN Chinese (China) 病程记录 - 推荐 C-CDA R2.0 与 R2.1 小节:-:时间点:{环境}:-:
Synonyms: C 型;丙;丙型 事件发生的地方;场景;环境;背景 先天性红细胞生成异常性贫血 先天性红细胞生成异常性贫血（Congenital dyserythropoietic anaemia，CDA） 先天性红细胞生成障碍性贫血 先天性红血球生成不良性贫血 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.文档;文书组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目）;文件医嘱组;医疗文书医嘱组;医疗文件医嘱组 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 病程（进展、病程进展、病情进展、进展情况、变化情况、发展情况）记录 - 推荐（建议） C-CDA R2.0 与 R2.1 小节（章节、部分）;Consolidated-Clinical Document Architecture;联合临床文档架构;统一临床文档架构;C-CDA;HL7 临床文档架构;HL7 Clinical Document Architecture;HL7 CDA 病程（进展、病程进展、病情进展、进展情况、变化情况、发展情况）记录;病程进展记录;病情进展记录 笔记;按语;注释;说明;票据;单据;证明书 组 组合 组合医嘱 组合类 组套

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=81216-4
Questionnaire definition
https://fhir.loinc.org/Questionnaire/?url=http://loinc.org/q/81216-4