Version 2.76

Term Description

This panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).
Source: Regenstrief LOINC

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
Indent77599-9 Additional documentation R
Indent77598-1 Externally defined clinical data elements Document R
Indent47420-5 Functional status assessment note R
Indent77597-3 Orders placed Document R
Indent18776-5 Plan of care note R
Indent29762-2 Social history Narrative R
Indent77596-5 Transportation summary Document R
Indent42348-3 Advance directives O
Indent48765-2 Allergies R
Indent51847-2 Evaluation + Plan note R
Indent51848-0 Evaluation note R
Indent46239-0 Chief complaint+Reason for visit Narrative R
Indent10154-3 Chief complaint Narrative - Reported R
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative R
Indent10157-6 History of family member diseases Narrative R
Indent10210-3 Physical findings of General status Narrative R
Indent61146-7 Goals Narrative R
Indent75310-3 Health concerns Document R
Indent11383-7 Patient problem outcome Narrative R
Indent11348-0 History of Past illness Narrative R
Indent10164-2 History of Present illness Narrative R
Indent11369-6 History of Immunization Narrative R
Indent69730-0 Instructions R
Indent62387-6 Interventions Narrative R
Indent46264-8 History of medical device use R
Indent10160-0 History of Medication use Narrative R
Indent10190-7 Mental status Narrative R
Indent61144-2 Diet and nutrition Narrative R
Indent61149-1 Objective Narrative R
Indent48768-6 Payment sources Document R
Indent29545-1 Physical findings Narrative R
Indent11450-4 Problem list - Reported R
Indent47519-4 History of Procedures Document R
Indent42349-1 Reason for referral (narrative) R
Indent29299-5 Reason for visit Narrative R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent10187-3 Review of systems Narrative - Reported R
Indent61150-9 Subjective Narrative R
Indent8716-3 Vital signs R

Fully-Specified Name

Component
Enhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections
Property
-
Time
Pt
System
{Setting}
Scale
-
Method

Additional Names

Short Name
Encd Encounter Nte CDP1 R1.0+1.1

Basic Attributes

Class
PANEL.DOC
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.58
Panel Type
Convenience group

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de encuentro mejorada: secciones recomendadas de CDP Set 1 R1.0 y R1.1:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Nota incontro arricchita-sezioni CDP Set 1 R1.0 & R1.1 raccomandate:-:Pt:{Setting}:-:
Synonyms: Panel documentazione Punto nel tempo (episodio)
zh-CN Chinese (China) 增强型就医记录 - 推荐 CDP 集合 1 R1.0 与 R1.1 小节:-:时间点:{环境}:-:
Synonyms: Ⅰ I 事件发生的地方;场景;环境;背景 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 增强型(加强型、改进型)就医(就医过程、就诊、邂逅、就诊过程、接触过程、接触、遭遇、遭遇过程、医患交互、医患互动、医患相互作用、医患接触过程)记录 - 推荐(建议) CDP 集合(集、代码集、取值集合、值集) 1 R1.0 与 R1.1 小节(章节、部分);HL7 Clinical Documents for Payers;HL7 支付方临床文档;HL7 CDP;美国地域;HL7 临床文档架构;HL7 Clinical Document Architecture;HL7 CDA 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 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=81243-8
Questionnaire definition
https://fhir.loinc.org/Questionnaire/?url=http://loinc.org/q/81243-8