77599-9 Additional documentation

Term Description

This document contains additional documentation captured by the provider related to care provided or planned for the patient that is not supported in any other section of the document. This term was created for, but not limited in use to, the Additional documentation section in the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.

Observation Required in Panel

Required

Fully-Specified Name

Component

Additional documentation

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.52

Last Updated

Version 2.63 (MIN)

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

Member of these Panels

Language Variants Get Info

Related Names

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

77598-1 Externally defined clinical data elements Document

Term Description

Externally defined clinical data elements section contains data that may be created through the interaction of the provider with templates (internal to the EHR or externally defined) that store XML tagged name-value pairs or more complex XML tagged information/content models and a reference to the externally defined information/content model, value set or clinical vocabulary. The referenced content model, value set or clinical vocabulary shall be pointed to by a URI in the Externally Defined CDA organizer and the specific XML tagged data shall be included in the Externally Defined CDE template. This term was created for, but not limited in use to, the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.

Observation Required in Panel

Required

Fully-Specified Name

Component

Externally defined clinical data elements

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.52

Last Updated

Version 2.63 (MIN)

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

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Externally defined CDEs
• Finding
• Findings
• MISC
• Point in time
• Random

47420-5 Functional Status Assessment Note

Term Description

Functional status assessment describes the patient's status of normal functioning at the time a care record was created. Functional statuses include information regarding the patient relative to ambulatory ability, mental status or competency, activities of daily living (ADLs) (i.e. bathing, dressing, feeding, grooming), home/living situation having an effect on the health status of the patient, ability to care for self, social activity (i.e. issues with social cognition, participation with friends and acquaintances other than family members), occupation activity (i.e. activities partly or directly related to working), housework or volunteering, family and home responsibilities or activities related to home and family, communication ability (i.e. issues with speech, writing or cognition required for communication), and perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance.

Observation Required in Panel

Required

Fully-Specified Name

Component

Functional status assessment note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.67 (MIN)

Change Reason

Previous Releases: Based on Clinical LOINC Committee approval on 2/17/2012, "note" was added to the Component as the Kind of Document.; 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

HL7^® Attachment Structure

No IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• Functional status note
• notes
• Point in time
• Random
• Visit note

77597-3 Orders placed Document

Term Description

Orders placed section contains active and completed (not planned) orders for observations, interventions, encounters, services, and procedures for the patient. Order information is used to validate that clinical activities performed by other providers and suppliers authorized by the responsible provider. The details of orders are provided but not the acts involved in the processing and fulfillment of the order. In general, planned order activity is included under the plan of treatment section (also known as "plan of care") LOINC 18776-5. This term was created for, but not limited in use to, the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.

Observation Required in Panel

Required

Fully-Specified Name

Component

Orders placed

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.52

Last Updated

Version 2.63 (MIN)

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

Member of these Panels

Language Variants Get Info

Related Names

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

18776-5 Plan of Care Note

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Plan of care note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 1.0l

Last Updated

Version 2.67 (MIN)

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.

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Allergies and adverse reactions Document

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

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

51847-2 Evaluation + Plan Note

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation+Plan note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.81 (MIN)

Change Reason

Release 2.81: ValidHL7AttachmentRequest: Updated to add to HIPAA Attachments, per user request.; 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

HL7^® Attachment Structure

No IG exists

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 Evaluation Note

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.73 (MIN)

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

10210-3 Physical findings of General status Narrative

Term Description

Physical findings (of general status) describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.

Observation Required in Panel

Required

Fully-Specified Name

Component

Physical findings

Property

Find

Time

Pt

System

General status

Scale

Nar

Method

Observed

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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

61146-7 Goals Narrative

Observation Required in Panel

Required

Fully-Specified Name

Component

Goals

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Both

Common Test Rank Get Info

6503

Member of these Panels

Language Variants Get Info

Related Names

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

75310-3 Health concerns Document

Term Description

A section that contains data describing an interest or worry about a health state or process that could possibly require attention, intervention, or management.

Observation Required in Panel

Required

Fully-Specified Name

Component

Health concerns

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

HL7.CCDA

Type

Clinical

First Released

Version 2.50

Last Updated

Version 2.63 (MIN)

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Finding
• Findings
• health concern
• HL7CCDA
• Point in time
• Random

11383-7 Patient problem outcome Narrative

Observation Required in Panel

Required

Fully-Specified Name

Component

Patient problem outcome

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.40 (MIN)

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

18841-7 Hospital consultations Document

Observation Required in Panel

Required

Fully-Specified Name

Component

Hospital consultations

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 1.0l

Last Updated

Version 2.67 (MAJ)

Change Reason

Release 2.67: PROPERTY: Corrected the Property since this concept represents a collection of information.

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

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

8648-8 Hospital course note

Term Description

Hospital course describes the sequence of events from admission to discharge in a hospital facility.

Observation Required in Panel

Required

Fully-Specified Name

Component

Hospital course note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H+P
• H+P.HX
• Hosp
• notes
• P prime
• Point in time
• Random
• Visit note

11369-6 History of Immunization note

Term Description

History of immunizations defines a patient's immunization status for the context and use case of the document type. Often included is current immunization status and possibly the entire immunization history.

Observation Required in Panel

Required

Fully-Specified Name

Component

Immunization note

Property

Hx

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; Previous Releases: Changed Component from "History of immunizations" to "Immunization", Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• H+P
• H+P.HX
• History
• Immunization status
• notes
• P prime
• Point in time
• Random
• Vaccination
• Vaccinations
• Vaccine
• Visit note

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Instructions

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.38

Last Updated

Version 2.73 (MIN)

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Interventions

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.73 (MIN)

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

46264-8 History of medical device use

Term Description

History of medical device (medical equipment) use defines a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history. This term is also used to itemize any pertinent current or historical durable medical equipment (DME) used to help maintain the patient's health status. All pertinent equipment relevant to the diagnosis, care, and treatment of a patient should be included.

Observation Required in Panel

Required

Fully-Specified Name

Component

History of medical device use

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.67 (MIN)

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

Observation

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• H/O
• Hx
• Medical device use Hx
• MISC
• Point in time
• Random

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

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

10190-7 Mental status Narrative

Term Description

Observations and evaluations related to a patient's psychological and mental competency and deficits including, but not limited to any of the following types of information: appearance, attitude, behavior/psychomotor, mood and affect, speech and language, thought process, thought content, perception, cognition, and insight and judgment.

Observation Required in Panel

Required

Fully-Specified Name

Component

Mental status

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Observed

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.58 (MIN)

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

61144-2 Diet and nutrition Narrative

Term Description

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

Observation Required in Panel

Required

Fully-Specified Name

Component

Diet and nutrition

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.63 (MIN)

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Objective

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.73 (MIN)

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

48768-6 Payment sources Document

Term Description

Contains data on the patient's payers, whether a 'third party' insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient's care.

Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient's pertinent current payment sources should be listed.

Observation Required in Panel

Required

Fully-Specified Name

Component

Payment sources

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Financing and insurance
• Finding
• Findings
• MISC
• Payers
• Point in time
• Random

29545-1 Physical findings note

Observation Required in Panel

Required

Fully-Specified Name

Component

Physical findings note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• notes
• P prime
• Phys find
• Point in time
• Random
• Visit note

11450-4 Problem list - Reported

Observation Required in Panel

Required

Fully-Specified Name

Component

Problem list

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

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

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

47519-4 History of Procedures Document

Term Description

This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically and at the time the document is generated.

Observation Required in Panel

Required

Fully-Specified Name

Component

History of procedures

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

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.;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Finding
• Findings
• H/O
• H+P
• H+P.HX
• Hx
• P prime
• Point in time
• Procedures Hx
• Random

30954-2 Relevant diagnostic tests/laboratory data note

Observation Required in Panel

Required

Fully-Specified Name

Component

Relevant diagnostic tests &or laboratory data note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

VACCIN

Type

Clinical

First Released

Version 2.04

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Relevant Dx tests/lab data
• Relevant dx tests/lab data note
• VACCINE
• Visit note

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Subjective

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.73 (MIN)

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

11537-8 Surgical drains Narrative

Observation Required in Panel

Required

Fully-Specified Name

Component

Surgical drains

Property

Find

Time

Pt

System

Surgical procedure

Scale

Nar

Method

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

• CLIN
• Finding
• Findings
• Narrative
• Point in time
• Random
• Report
• Surg

8716-3 Vital signs note

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

Vital signs note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed