51847-2 Assessment+Plan

Term Description

The Assessment and Plan note (also called impression or diagnoses) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block. The Plan section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education was given or will be provided.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation+Plan note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Eval+Plan note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.63

Change Reason

Previous Releases: Changed 'Assesment' to 'Evaluation' to harmonize existing terms with similar meaning. The term 'Evaluation' will be used in the LOINC Document Ontoloy based on Clinical LOINC Committee decision (Sept 2014).; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;

Order vs. Observation

Both

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Assessment
• Assessment+Plan note
• DOC.ONT
• Document
• Encounter
• Eval
• Eval+Plan note
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H&P
• History and physical
• notes
• Point in time
• Random
• Visit note

51848-0 Assessment

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Eval note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.73

Change Reason

Previous Releases: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;

Order vs. Observation

Both

Common Test Rank Get Info

6628

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Assessment
• DOC.ONT
• Document
• Encounter
• Eval
• Eval note
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H&P
• History and physical
• notes
• Point in time
• Random
• Visit note

18776-5 Plan of care

Term Description

Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Plan of care note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Plan of care note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 1.0l

Last Updated

Version 2.67

Change Reason

Previous Releases: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.;

Order vs. Observation

Both

HL7^® Attachment Structure

IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Care plan
• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Treatment plan
• Visit note

48765-2 Allergies

Term Description

Contains a list and description of any allergies or adverse reactions pertinent to current or past medical history. At a minimum this section should contain currently active and any relevant historical allergies and adverse reactions.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Additional Names

Short Name

Allergies &or adverse reactions Doc

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73

Change Reason

Previous Releases: Edited Component part from "Allergies, adverse reactions, alerts" to "Allergies &or adverse reactions." We removed the word "alerts" because it was potentially confusing by implying that it may contain other kinds of warnings (as a arbitrary example: public health disease outbreak notifications) when in fact it was always intended to be the typical "allergies" section.;

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• MISC
• Point in time
• Random

10154-3 Chief complaint Narrative - Reported

Term Description

Chief complaint records the patient's primary complaint (the patient's own description).
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Chief complaint

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Additional Names

Short Name

Chief complaint Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

69730-0 Instructions

Term Description

The Instructions section records instructions given to a patient. Examples of what it might contain include: instructions about not resuming normal activities, potential complications, use of medications, follow-up with healthcare providers, etc.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Instructions

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Instructions

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.38

Last Updated

Version 2.73

Change Reason

Previous Releases: Updated System, Scale and Property to harmonize with the currently LOINC Document Ontology model.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;

Order vs. Observation

Both

Common Test Rank Get Info

3636

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• DOC.ONT
• Document
• Finding
• Findings
• Point in time
• Random

62387-6 Interventions Narrative

Term Description

This term was originally created for, though not limited in use to, the HL7 Implementation Guide for CDA: Progress Note. The Interventions section contains information about the specific interventions provided during the healthcare visit. Depending on the type of intervention(s) provided (procedural, education, application of assistive equipment, etc.), the details will vary but may include specification of frequency, intensity, and duration.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Interventions

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Interventions

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

10160-0 History of Medication use Narrative

Term Description

History of medication use defines a patient's current medications and history of pertinent medications. This term may also include a patient's prescription and dispense history.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Medication use

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Change Reason

Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Narrative
• P prime
• Point in time
• Random
• Report

61144-2 Diet and nutrition Narrative

Term Description

This section houses diet information such as special diets, restrictions, NPO, liquids only, etc..
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Diet and nutrition

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Diet+nutrition

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

• Diet+nutrition
• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

61149-1 Objective Narrative

Term Description

This term was originally created for, though not limited in use to, the HL7 Implementation Guide for CDA: Progress Note. The Objective section contains data about the patient gathered through tests, measures, or observations that produce a quantified or categorized result. It includes important and relevant positive and negative test results, physical findings, review of systems, and other measurements and observations.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Objective

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Objective

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

29545-1 Physical findings Narrative

Observation Required in Panel

Optional

Fully-Specified Name

Component

Physical findings

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Observed

Additional Names

Short Name

Phys find

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• Narrative
• P prime
• Phys find
• Point in time
• Random
• Report

11450-4 Problem list - Reported

Observation Required in Panel

Optional

Fully-Specified Name

Component

Problem list

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Reported

Additional Names

Short Name

Problem list Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.73

Common Test Rank Get Info

9889

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Nominal
• P prime
• Point in time
• Random

30954-2 Results

Observation Required in Panel

Optional

Fully-Specified Name

Component

Relevant diagnostic tests &or laboratory data

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Relevant Dx tests/lab data

Basic Attributes

Class

VACCIN

Type

Clinical

First Released

Version 2.04

Last Updated

Version 2.63

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• Narrative
• Point in time
• Random
• Relevant Dx tests/lab data
• Report
• VACCINE

10187-3 Review of systems Narrative - Reported

Term Description

The Review of systems section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Review of systems

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Additional Names

Short Name

Review of systems

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

61150-9 Subjective Narrative

Term Description

This term was originally created for, though not limited in use to, the HL7 Implementation Guide for CDA: Progress Note. The Subjective section describes in a narrative format the patient's current condition and/or interval changes as reported by the patient or by the patient's guardian or another informant.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Subjective

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Subjective

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

8716-3 Vital signs

Term Description

The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component

Vital signs

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Observed

Additional Names

Short Name

Vital signs

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.73

Common Test Rank Get Info

576

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.PX
• Narrative
• P prime
• Point in time
• Random
• Report