Version 2.79

11329-0 History general

Term Description

History general describes all aspects of medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. It may also be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Past Medical History and Social History.

Observation Required in Panel

Optional

Fully-Specified Name

Component
History general
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Reported

Long Common Name

History general Narrative - Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73 (MIN)
Common Test Rank Get Info
3158

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Ιστορικό γενικά:Εύρεση:Pt:^Ασθενής:Nar:Αναφερόμενη
Synonyms: Εύρεση
es-MX Spanish (Mexico) Historia general:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
es-AR Spanish (Argentina) antecedentes generales:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
fr-BE French (Belgium) Histoire générale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
Synonyms: Anamn?se
it-IT Italian (Italy) Storia generale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) voorgeschiedenis algemeen:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) История общая:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Общий анамнез Описательный Точка во времени;Момент
zh-CN Chinese (China) 一般病史:发现:时间点:^患者:叙述型:报告法
Synonyms: 一般史;一般历史;普通历史;普通史;普通病史 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查

55115-0 Request (Radiology)

Term Description

Information on requested imaging studies and associated tests. It may include information on the reason for the request.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Requested imaging studies information
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Long Common Name

Requested imaging studies information Document

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Ζητούμενες πληροφορίες απεικονιστικών μελετών:Εύρεση:Pt:^Ασθενής:Doc:
Synonyms: Εύρεση Ζητούμενες πληροφορίες απεικονιστικών μελετών
es-MX Spanish (Mexico) Información de estudios de imagen solicitados:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Studi di imaging richiesti, informazioni:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Informazioni su studi di imaging richiesti Miscellanea Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Запрошенные визуализация исследования информация:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Информация о запрошенных исследованиях по визуализации Точка во времени;Момент
zh-CN Chinese (China) 已申请成像检查信息:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 已申请成象检查信息;已申请成象技术检查信息;已申请影像学检查信息;已申请显像检查信息;已申请透视显像检查信息;已申请成像检查项目;已申请的成像检查的信息;已请求成像检查信息 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

55111-9 Current imaging procedure descriptions Document

Term Description

Contains information on current imaging studies and associated tests.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Current imaging procedure descriptions
Property
Desc
Time
Pt
System
^Patient
Scale
Doc
Method

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Περιγραφές τρέχουσας διαδικασίας απεικόνισης:Desc:Pt:^Ασθενής:Doc:
Synonyms: Desc Διαδικασία Περιγραφές τρέχουσας διαδικασίας απεικόνισης
es-MX Spanish (Mexico) Descripciones de los procedimientos de diagnóstico por imágenes actuales:Desc:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Descrizioni attuale procedure di imaging:Desc:Pt:^Paziente:Doc:
Synonyms: Descrizione Descrizioni attuale procedura di diagnostica per i Documentazione miscellanea Miscellanea paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Текущее визуализация вмешательство описания:Опис:ТчкВрм:^Пациент:Док:
Synonyms: Документ Описание Процедура Точка во времени;Момент
zh-CN Chinese (China) 当前成像操作描述:描述:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 当前成像操作项目说明;当前成象操作描述;当前成象技术操作描述;当前影像学操作描述;当前显像操作描述;当前透视显像操作描述;当前成像操作项目描述 操作;程序;手续;步骤;规程;程序流程 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 说明

55114-3 Prior procedure descriptions

Term Description

Contains information on past imaging studies and associated tests.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Prior imaging procedure descriptions
Property
Desc
Time
Pt
System
^Patient
Scale
Doc
Method

Long Common Name

Prior imaging procedure descriptions Document

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Περιγραφές προηγούμενης διαδικασίας απεικόνισης:Desc:Pt:^Ασθενής:Doc:
Synonyms: Desc Διαδικασία Περιγραφές προηγούμενης διαδικασίας απεικόνισης
es-MX Spanish (Mexico) Descripciones de procedimientos de diagnóstico por imágenes previos:Desc:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Precedente procedura di imaging, descrizioni:Desc:Pt:^Paziente:Doc:
Synonyms: Descrizione Descrizioni precedente procedura di imaging Documentazione miscellanea Miscellanea paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Предшествующая визуализация вмешательство описания:Опис:ТчкВрм:^Пациент:Док:
Synonyms: Документ Описание Описания предшествовавших вмешательств по визуализации Процедура Точка во времени;Момент
zh-CN Chinese (China) 既往成像操作描述:描述:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 操作;程序;手续;步骤;规程;程序流程 文档.其他;杂项类文档;其他文档 既往成像操作项目说明;既往成象操作描述;既往成象技术操作描述;既往影像学操作描述;既往显像操作描述;既往透视显像操作描述;既往成像操作项目描述;之前成像操作描述 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 说明

18834-2 Radiology Comparison study - observation

Observation Required in Panel

Optional

Fully-Specified Name

Component
Comparison.study
Property
Imp
Time
Pt
System
XXX
Scale
Nar
Method
Radiology

Long Common Name

Radiology Comparison study (narrative)

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
85430-7 Diagnostic imaging report - example sections and entries
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σύγκριση.μελέτη:Imp:Pt:XXX:Nar:Ακτινολογία
Synonyms: Imp
es-AR Spanish (Argentina) estudio.comparativo:impresión/interpretación del estudio:punto en el tiempo:XXX:Narrativo:radiología
it-IT Italian (Italy) Confronto.studio:Imp:Pt:XXX:Nar:Radiologia
Synonyms: Allegato Allegato referto clinico Impressione/interpretazione di studio Punto nel tempo (episodio) Studio comparativo
nl-NL Dutch (Netherlands) vergelijkend onderzoek:interpretatie:moment:XXX:tekstueel:radiologie
pt-BR Portuguese (Brazil) Estudo.comparativo:Imp:Pt:XXX:Nar:Radiologia
Synonyms: Interpretation; Interp; Impression; Impressions; Point in time; Random; Misc; Miscellaneous; Unspecified; Other; Narrative; Report; Compare
zh-CN Chinese (China) 比较.检查:印象:时间点:XXX:叙述型:放射医学
Synonyms: 不明的;其他;将在相应消息内其他部分之中加以详细说明;未作详细说明的;未作说明的;未做说明的标本;未加规定的;未加说明的标本;杂项 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 时刻;随机;随意;瞬间 检查分析 比较.研究 研究;检查项目;调查;考察;研究项目;学习 考察 调查

18782-3 Radiology Study observation (findings)

Term Description

Radiology study observation (or Findings) contains the main narrative body of a radiology report. While not an absolute requirement for transformed DICOM SR reports, it is suggested that Diagnostic Imaging Reports authored in CDA follow Term Info guidelines for the codes in the various observations and procedures recorded in this section.

Observation Required in Panel

Required

Fully-Specified Name

Component
Study observation
Property
Find
Time
Pt
System
XXX
Scale
Nar
Method
Radiology

Long Common Name

Radiology Study observation (narrative)

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
26443-2 Clinical reports.non lab claims attachment
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
85430-7 Diagnostic imaging report - example sections and entries
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Untersuchung:Ergebnis:Zeitpunkt:XXX:Freitext:Radiologie
Synonyms: Befund
el-GR Greek (Greece) Παρατήρηση μελέτης:Εύρεση:Pt:XXX:Nar:Ακτινολογία
Synonyms: Εύρεση
es-AR Spanish (Argentina) STUDY OBSERVATION:hallazgo:punto en el tiempo:XXX:Narrativo:radiografía
it-IT Italian (Italy) Rilievo:Osservazione:Pt:XXX:Nar:Radiologia
Synonyms: Allegato Allegato referto clinico Osservazione Osservazione di studio Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) observatieonderzoek:bevinding:moment:XXX:tekstueel:radiologie
pt-BR Portuguese (Brazil) Observação:Achado:Pt:XXX:Nar:RX
Synonyms: Finding; Findings; Point in time; Random; Misc; Miscellaneous; Unspecified; Other; Narrative; Report
zh-CN Chinese (China) 检查观察结果:发现:时间点:XXX:叙述型:放射医学
Synonyms: 不明的;其他;将在相应消息内其他部分之中加以详细说明;未作详细说明的;未作说明的;未做说明的标本;未加规定的;未加说明的标本;杂项 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 时刻;随机;随意;瞬间 检查;检查观察 检查分析 研究;检查项目;调查;考察;研究项目;学习 考察 观测 调查

19005-8 Radiology - Impression

Observation Required in Panel

Optional

Fully-Specified Name

Component
Imaging study
Property
Imp
Time
Pt
System
XXX
Scale
Nar
Method
Radiology

Long Common Name

Radiology Imaging study [Impression] (narrative)

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
85430-7 Diagnostic imaging report - example sections and entries
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Μελέτη απεικόνισης:Imp:Pt:XXX:Nar:Ακτινολογία
Synonyms: Imp
es-AR Spanish (Argentina) impresión de rayos X:impresión/interpretación del estudio:punto en el tiempo:XXX:Narrativo:radiología
it-IT Italian (Italy) Studio di imaging:Imp:Pt:XXX:Nar:Radiologia
Synonyms: Allegato Allegato referto clinico Impressione/interpretazione di studio Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) beeldvormend onderzoek:interpretatie:moment:XXX:tekstueel:radiologie
pt-BR Portuguese (Brazil) Estudo radiológico:Imp:Pt:XXX:Nar:Radiologia
Synonyms: Interpretation; Interp; Impression; Impressions; Point in time; Random; Misc; Miscellaneous; Unspecified; Other; Narrative; Report
zh-CN Chinese (China) 成像检查:印象:时间点:XXX:叙述型:放射医学
Synonyms: 不明的;其他;将在相应消息内其他部分之中加以详细说明;未作详细说明的;未作说明的;未做说明的标本;未加规定的;未加说明的标本;杂项 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 成象检查;成象技术检查;影像学检查;显像检查;透视显像检查;成像检查项目 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 时刻;随机;随意;瞬间 检查分析 研究;检查项目;调查;考察;研究项目;学习 考察 调查

18783-1 Radiology Study recommendation

Observation Required in Panel

Optional

Fully-Specified Name

Component
Study recommendation
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method
Radiology

Long Common Name

Radiology Study recommendation (narrative)

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
85430-7 Diagnostic imaging report - example sections and entries
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σύσταση μελέτης:Imp:Pt:^Ασθενής:Nar:Ακτινολογία
Synonyms: Imp
es-AR Spanish (Argentina) recomendación del estudio:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:radiología
it-IT Italian (Italy) Raccomandazione studio:Imp:Pt:^Paziente:Nar:Radiologia
Synonyms: Allegato Allegato referto clinico Consiglio Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) onderzoek aanbeveling:interpretatie:moment:^patiënt:tekstueel:radiologie
zh-CN Chinese (China) 检查建议:印象:时间点:^患者:叙述型:放射医学
Synonyms: 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 劝告;介绍;推荐;介绍信 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 时刻;随机;随意;瞬间 检查分析 检查项目建议;检查劝告;检查推荐 研究;检查项目;调查;考察;研究项目;学习 考察 调查

55110-1 Conclusions

Term Description

Contains conclusions and diagnoses that result from the interpretation process.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Conclusions
Property
Imp
Time
Pt
System
^Patient
Scale
Doc
Method

Long Common Name

Conclusions [Interpretation] Document

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Συμπεράσματα:Imp:Pt:^Ασθενής:Doc:
Synonyms: Imp Συμπεράσματα
es-MX Spanish (Mexico) Conclusiones:Interpretación:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Conclusioni:Imp:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Impressione/interpretazione di studio Miscellanea paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) conclusies:interpretatie:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Выводы:Впчт:ТчкВрм:^Пациент:Док:
Synonyms: Впечатление/интерпретация исследования Документ Заключения Точка во времени;Момент
zh-CN Chinese (China) 结论:印象:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 决定;结束语;结语;最后的总结 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

55107-7 Addendum

Term Description

Supplementary information or an appendix added to the original document contents.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Addendum
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Long Common Name

Addendum Document

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both
Common Test Rank Get Info
4616

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anhang:Befund:Zeitpunkt:^Patient:Dokument:
el-GR Greek (Greece) Παράρτημα:Εύρεση:Pt:^Ασθενής:Doc:
Synonyms: Εύρεση Παράρτημα
es-ES Spanish (Spain) Adenda:Hallazgo:Punto temporal:^paciente:Doc:
es-MX Spanish (Mexico) Apéndice:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Appendice:Osservazione:Pt:^Paziente:Doc:
Synonyms: Aggiunta Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) addendum:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Дополнение:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Аддендум Документ Точка во времени;Момент
zh-CN Chinese (China) 补遗:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 附录;补充;附件

18785-6 Radiology Reason for study

Observation Required in Panel

Optional

Fully-Specified Name

Component
Reason for study
Property
Find
Time
Pt
System
Report
Scale
Nar
Method
Radiology

Long Common Name

Radiology Reason for study (narrative)

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63 (MIN)

Member of these Panels

LOINC Long Common Name
85430-7 Diagnostic imaging report - example sections and entries
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Λόγος μελέτης:Εύρεση:Pt:Αναφορά:Nar:Ακτινολογία
Synonyms: Εύρεση
es-AR Spanish (Argentina) motivo para el estudio:hallazgo:punto en el tiempo:informe:Narrativo:radiología
it-IT Italian (Italy) Motivo per lo studio:Osservazione:Pt:Referto:Nar:Radiologia
Synonyms: Allegato Allegato referto clinico Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) reden voor onderzoek:bevinding:moment:verslag:tekstueel:radiologie
zh-CN Chinese (China) 关于检查的原因:发现:时间点:报告:叙述型:放射医学
Synonyms: 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 关于检查的理由;检查原因;检查理由 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 报道;汇报;调查报告;报表;报导 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 时刻;随机;随意;瞬间 检查分析 研究;检查项目;调查;考察;研究项目;学习 考察 调查

55108-5 Patient presentation

Term Description

Aspects of the patient that are specific to this clinical presentation, e.g.: transferred from, admission date/time, indications for procedure, etc.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Clinical presentation
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Long Common Name

Clinical presentation Document

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Κλινική εικόνα:Εύρεση:Pt:^Ασθενής:Doc:
Synonyms: Εύρεση Κλινική εικόνα
es-MX Spanish (Mexico) Presentación clínica:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Presentazione clinica:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) klinische presentatie:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Клиническая презентация:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 临床表现:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

55109-3 Complications

Term Description

Information on additional medical problems that develop following a procedure, diagnostic test or study, treatment, or illness.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Complications
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Long Common Name

Complications Document

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
62863-6 PhenX domain - Infectious diseases and immunity
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Επιπλοκές:Εύρεση:Pt:^Ασθενής:Doc:
Synonyms: Επιπλοκές Εύρεση
es-MX Spanish (Mexico) Complicaciones:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Complicazioni:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) complicaties:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Осложнения:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 并发症:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 合并症 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

55112-7 Summary

Term Description

The essence of the document.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Document summary
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Long Common Name

Document summary

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σύνοψη εγγράφου:Εύρεση:Pt:^Ασθενής:Doc:
Synonyms: Εύρεση Σύνοψη εγγράφου
es-MX Spanish (Mexico) Resumen del documento:Tipo:Punto temporal:^ Paciente:Documento:
fr-FR French (France) Résumé de document:Recherche:Ponctuel:Patient:Document:
it-IT Italian (Italy) Documento di sintesi:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) documentsamenvatting:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Документ краткие сведения:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 文档摘要:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 摘要（小结、概要、总结、梗概、概括、总汇）;医疗文书摘要;文件摘要 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

55113-5 Key images

Term Description

List of references to images considered significant.

Observation Required in Panel

Optional

Fully-Specified Name

Component
Key images
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method
Radiology

Long Common Name

Key images Document Radiology

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73 (MIN)
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Schlüsselbilder:Ergebnis:Zeitpunkt:^Patient:Dokument:Radiologie
Synonyms: KOS Objekte
el-GR Greek (Greece) Βασικές εικόνες:Εύρεση:Pt:^Ασθενής:Doc:Ακτινολογία
Synonyms: Βασικές εικόνες Εύρεση
es-MX Spanish (Mexico) Imágenes clave:Tipo:Punto temporal:^ Paciente:Documento:Radiology
it-IT Italian (Italy) Immagini chiave:Osservazione:Pt:^Paziente:Doc:Radiologia
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) sleutelbeelden:bevinding:moment:^patiënt:document:radiologie
zh-CN Chinese (China) 关键图像:发现:时间点:^患者:文档型:放射医学
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 关键图象;关键图片;关键图形 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验