81615-7
Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
Active
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Additional documentation
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Additional documentation
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.52
- Last Updated
- Version 2.63
- 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
LOINC | Long Common Name |
---|---|
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 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 |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Ergänzende Dokumentation: |
es-MX | Spanish (Mexico) | Documentación adicional: |
it-IT | Italian (Italy) | Ulteriore documentazione: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato |
zh-CN | Chinese (China) | 附加文档记录: Synonyms: 临床文档型; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Externally defined clinical data elements
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Externally defined CDEs Doc
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.52
- Last Updated
- Version 2.63
- 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
LOINC | Long Common Name |
---|---|
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 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 |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Elementos de datos clínicos definidos externamente: |
it-IT | Italian (Italy) | Dati clinici definiti esternamente: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato |
zh-CN | Chinese (China) | 外部定义型临床数据元: Synonyms: 临床(临床医疗、 |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Functional status assessment note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Functional status note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.19
- Last Updated
- Version 2.67
- 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
LOINC | Long Common Name |
---|---|
81898-9 | Composite triage and nursing note - recommended IHE set |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
74449-0 | Patient plan of care - recommended IHE set |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Member of these Groups Get Info
LOINC Group | Group Name |
---|---|
LG41826-5 | {Setting}| |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Funktionelle Statusbeurteilung - Notiz: |
es-MX | Spanish (Mexico) | Nota de evaluación del estado funcional: |
it-IT | Italian (Italy) | Stato funzionale, nota di valutazione: Synonyms: Documentazione dell''ontologia Nota di valutazione dello stato funzionale Osservazione Punto nel tempo (episodio) Ruolo non specificato |
nl-NL | Dutch (Netherlands) | beoordeling van functioneren: |
zh-CN | Chinese (China) | 功能状态评估记录: Synonyms: 临床文档型; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Orders placed
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Orders placed Doc
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.52
- Last Updated
- Version 2.63
- 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
LOINC | Long Common Name |
---|---|
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 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 |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Pedidos realizados: |
it-IT | Italian (Italy) | Oridini fatti: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato |
zh-CN | Chinese (China) | 已下达的医嘱: Synonyms: 临床文档型; |
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.
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
LOINC | Long Common Name |
---|---|
57082-0 | Antepartum record panel |
69459-6 | Care record summary panel |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 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 |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral 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 |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Member of these Groups Get Info
LOINC Group | Group Name |
---|---|
LG41826-5 | {Setting}| |
LG38745-2 | Plan of care note| |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Behandlungsplan - Notiz: |
es-AR | Spanish (Argentina) | plan de tratamiento: |
es-MX | Spanish (Mexico) | Nota del plan de cuidados: |
it-IT | Italian (Italy) | Piano di cura, nota: Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio) Ruolo non specificato |
nl-NL | Dutch (Netherlands) | behandelplan: Synonyms: zorgplan |
zh-CN | Chinese (China) | 医疗服务计划记录: Synonyms: 临床文档型; |
29762-2 Social history Narrative
Term Description
The Social history section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Social history
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Social Hx
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.63
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Sozialanamnese: |
es-AR | Spanish (Argentina) | antecedentes sociales: |
es-MX | Spanish (Mexico) | Historia social: |
fr-BE | French (Belgium) | Histoire sociale: |
it-IT | Italian (Italy) | Storia sociale: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | sociale geschiedenis: |
pt-BR | Portuguese (Brazil) | Histórico social: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Социальная история: Synonyms: Описательный Социальный анамнез Точка во времени; |
zh-CN | Chinese (China) | 社会史: Synonyms: 医疗服务对象; |
77596-5 Transportation summary Document
Term Description
A transportation summary includes the method (such as emergency transport) that was used to bring the patient to the location for the current encounter. This information is often provided as a summary by the entity that provides the transportation service. This term was created for, but not limited in use to, the Transportation section in the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Transportation summary
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Transport summary Doc
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.52
- Last Updated
- Version 2.63
- 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
LOINC | Long Common Name |
---|---|
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Resumen de transporte: |
it-IT | Italian (Italy) | Transporto, riassunto: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Riassunto di trasporto Ruolo non specificato |
zh-CN | Chinese (China) | 运输摘要: Synonyms: 临床文档型; |
46241-6 Hospital admission diagnosis Narrative - Reported
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Hospital admission Dx
- Property
- Imp
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- Reported
Additional Names
- Short Name
- Hospital admission Dx Reported
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 2.19
- Last Updated
- Version 2.63
- Order vs. Observation
- Observation
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 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 |
59271-7 | Hospital discharge summary panel |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
82811-1 | Nurse summary note - recommended sections |
62863-6 | PhenX domain - Infectious diseases and immunity |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Admisión hospitalaria Dx: |
fr-BE | French (Belgium) | Documents admission hôpital: |
it-IT | Italian (Italy) | Ricovero ospedaliero, Dx: Synonyms: Anamnesi Diagnosi di ricovero ospedaliero; |
nl-NL | Dutch (Netherlands) | ziekenhuis opnamediagnose: |
pt-BR | Portuguese (Brazil) | Admissão hospitalar Dx: Synonyms: Hosp; |
ru-RU | Russian (Russian Federation) | Госпитализация Dx: Synonyms: Анамнестические сведения; |
zh-CN | Chinese (China) | 医院入院诊断: Synonyms: Dx 医疗服务对象; |
42346-7 Medications on admission (narrative)
Term Description
Admission can refer to hospital admission, long-term care admission, or home health admission.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Medications on admission
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Basic Attributes
- Class
- ATTACH.CLINRPT
- Type
- Claims Attachments
- First Released
- Version 2.16
- Last Updated
- Version 2.27
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Medikation bei Aufnahme: |
fr-FR | French (France) | Traitement lors de l'admission: |
fr-BE | French (Belgium) | Médications à admission: |
it-IT | Italian (Italy) | Farmaci al ricovero: Synonyms: Allegato Allegato referto clinico Farmaci al momento del ricovero Osservazione paziente Punto nel tempo (episodio) |
pt-BR | Portuguese (Brazil) | Medicamentos na internação: Synonyms: Finding; |
ru-RU | Russian (Russian Federation) | Лекарственные препараты при госпитализации: Synonyms: Лекарства Описательный Точка во времени; |
zh-CN | Chinese (China) | 入院时的药物: Synonyms: 临床报告信息附件; |
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
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
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
LOINC | Long Common Name |
---|---|
57082-0 | Antepartum record panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
82315-3 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Allergien und unerwünschte Wirkungen: |
es-MX | Spanish (Mexico) | Alergias y reacciones adversas: |
it-IT | Italian (Italy) | Allergie &o reazioni avverse: Synonyms: Allergie e reazioni avverse Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | allergieën en/of allergische reacties: |
ru-RU | Russian (Russian Federation) | Аллергии &или неблагоприятные реакции: Synonyms: Документ Точка во времени; |
zh-CN | Chinese (China) | 变态反应和或不良反应: Synonyms: 临床文档型; |
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}
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
LOINC | Long Common Name |
---|---|
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
82811-1 | Nurse summary note - recommended sections |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Member of these Groups Get Info
LOINC Group | Group Name |
---|---|
LG41826-5 | {Setting}| |
LG38847-6 | Evaluation note| |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Nota de evaluación: |
it-IT | Italian (Italy) | Valutazione, nota: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) Ruolo non specificato |
nl-NL | Dutch (Netherlands) | onderzoeksverslag: Synonyms: evaluatieverslag |
zh-CN | Chinese (China) | 评价记录: Synonyms: 临床文档型; |
46239-0 Chief complaint+Reason for visit Narrative
Term Description
This term is used to record the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Chief complaint+Reason for visit
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Chief complaint+Reason for visit
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 2.19
- Last Updated
- Version 2.63
- Order vs. Observation
- Observation
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Queja principal + Motivo de la visita: |
fr-BE | French (Belgium) | Plainte principale+raison de visite: |
it-IT | Italian (Italy) | Disturbo principale+Motivo dell'incontro: Synonyms: Anamnesi Disturbo primario Disturbo primario e Motivo dell''incontro Lamenta Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | belangrijkste klacht + reden voor bezoek: |
pt-BR | Portuguese (Brazil) | Reclamação à chefia+Motivo da visita: Synonyms: Finding; |
ru-RU | Russian (Russian Federation) | Основная жалоба+Причина визита: Synonyms: Описательный Причина визита Проблема; |
zh-CN | Chinese (China) | 主诉+就诊原因: Synonyms: 主诉+就诊理由; |
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
Required
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
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
84428-2 | National EMS Information System - version 3 set |
82811-1 | Nurse summary note - recommended sections |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
74028-2 | Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | motivo de consulta principal: |
es-MX | Spanish (Mexico) | Queja principal: |
fr-BE | French (Belgium) | Plainte principale: |
it-IT | Italian (Italy) | Disturbo principale: Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | belangrijkste klacht: |
ru-RU | Russian (Russian Federation) | Основная жалоба: Synonyms: Анамнестические сведения; |
zh-CN | Chinese (China) | 主诉: Synonyms: 医疗服务对象; |
11535-2 Hospital discharge Dx Narrative
Term Description
Hospital discharge diagnosis describes the patient's relevant problems or diagnoses that occurred during the hospitalization or that need to be followed after hospitalization.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Hospital discharge Dx
- Property
- Imp
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hospital discharge Dx
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Order vs. Observation
- Observation
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 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 |
57083-8 | Labor and Delivery record panel |
92576-8 | Maternal discharge summary - recommended IHE set |
82811-1 | Nurse summary note - recommended sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | diagnóstico al alta del hospital: |
es-MX | Spanish (Mexico) | Alta hospitalaria Dx: |
fr-BE | French (Belgium) | Documents sortie hôpital: |
it-IT | Italian (Italy) | Dimissione ospedaliera, Dx: Synonyms: Anamnesi Diagnosi di dimissione ospedaliera Impressione/interpretazione di studio paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | ziekenhuis onslagdiagnose: |
pt-BR | Portuguese (Brazil) | Alta hospitalar Dx: Synonyms: Hosp; |
ru-RU | Russian (Russian Federation) | Госпитализация выбытие Dx: Synonyms: Впечатление/интерпретация исследования Выписка Описательный Точка во времени; |
zh-CN | Chinese (China) | 医院出院诊断: Synonyms: Dx 允许...离开(医院、 |
10183-2 Hospital discharge medications Narrative
Term Description
Hospital discharge medications defines the medications that the patient is intended to take (or stop) after discharge. This may also include a patient's prescription history and indicate the source of the medication list, for example, from a pharmacy system versus from the patient.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Hospital discharge medications
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hospital discharge medications
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.63
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 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 |
59271-7 | Hospital discharge summary panel |
57083-8 | Labor and Delivery record panel |
92576-8 | Maternal discharge summary - recommended IHE set |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | medicación para el alta del hospital: |
es-MX | Spanish (Mexico) | Medicamentos para el alta hospitalaria: |
fr-BE | French (Belgium) | Médications sortie hôpital: |
it-IT | Italian (Italy) | Dimissione ospedaliera, farmaci: Synonyms: Anamnesi Farmaci di dimissione ospedaliera Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | ziekenhuis ontslagmedicatie: |
ru-RU | Russian (Russian Federation) | Госпитализация выбытие лекарственные препараты: Synonyms: Выписка Лекарства Описательный Точка во времени; |
zh-CN | Chinese (China) | 医院出院药物: Synonyms: 允许...离开(医院、 |
10157-6 History of family member diseases Narrative
Term Description
History of family member diseases is a report of health information, including medical, genetic, environmental, and lifestyle factors, pertaining to the patient and his or her genetic relatives (living or deceased). The family history information is used to determine possible or relevant health risk factors that may have a potential impact on the patient's healthcare risk profile.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- History of family member diseases
- Property
- Hx
- Time
- Pt
- System
- ^Family member
- Scale
- Nar
- Method
Additional Names
- Short Name
- Family member diseases Hx
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.73
- Change Reason
- Previous Releases: Changed Property from "Find" to "Hx", removed Method of "Reported" and corrected System from Family to ^Family member to align with existing family history terms and to represent family member as a Super System per 8/2015 Clinical LOINC Committee decision;
- Common Test Rank Get Info
- 9825
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
35089-2 | History and physical panel |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
35090-0 | Patient history |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | antecedentes de enfermedades en miembros familiares: |
es-MX | Spanish (Mexico) | Historia de enfermedades de miembros de la familia: |
fr-CA | French (Canada) | Antécédents familiaux: |
fr-BE | French (Belgium) | Anamnèse. Maladies dans la famille: |
it-IT | Italian (Italy) | Storia di malattie di membri familiari: Synonyms: Anamnesi Punto nel tempo (episodio) Storia di malattie di membri della famiglia Storia; |
nl-NL | Dutch (Netherlands) | geschiedenis van ziekte binnen de familie: Synonyms: anamnese ziekte in familieanamnese |
ru-RU | Russian (Russian Federation) | История член семьи заболевания: Synonyms: История Описательный Семейный анамнез заболеваний Точка во времени; |
zh-CN | Chinese (China) | 家族成员疾病史: Synonyms: 历史; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Physical findings
- Property
- Find
- Time
- Pt
- System
- General status
- Scale
- Nar
- Method
- Observed
Additional Names
- Short Name
- Phys find General status
Basic Attributes
- Class
- H&P.PX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.63
Member of these Panels
LOINC | Long Common Name |
---|---|
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | hallazgos físicos: |
es-MX | Spanish (Mexico) | Hallazgos físicos: |
it-IT | Italian (Italy) | Osservazioni fisiche: Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio) |
pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Физикальные находки: Synonyms: Общее состояние Описательный Точка во времени; |
zh-CN | Chinese (China) | 体格检查发现: Synonyms: 体格检查(查体、 |
61146-7 Goals Narrative
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Goals
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Goals
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.34
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 6503
Member of these Panels
LOINC | Long Common Name |
---|---|
81215-6 | Care plan - recommended C-CDA R2.0 and R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-ES | Spanish (Spain) | Objetivos: |
es-MX | Spanish (Mexico) | Metas: |
it-IT | Italian (Italy) | Obiettivi: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | doelen: |
ru-RU | Russian (Russian Federation) | Цели: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 目标: Synonyms: 医疗服务对象; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Health concerns
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Health concern Doc
Basic Attributes
- Class
- HL7.CCDA
- Type
- Clinical
- First Released
- Version 2.50
- Last Updated
- Version 2.63
- Order vs. Observation
- Both
Member of these Panels
LOINC | Long Common Name |
---|---|
81215-6 | Care plan - recommended C-CDA R2.0 and R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Preocupaciones de salud: |
it-IT | Italian (Italy) | Preoccupazioni per la salute: Synonyms: HL7 Consolidated Clinical Document Architecture Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | aandachtspunt betreffende gezondheid: |
zh-CN | Chinese (China) | 健康关注事项: Synonyms: HL7.统一临床文档架构; |
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
Additional Names
- Short Name
- Patient problem outcome
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.40
Member of these Panels
LOINC | Long Common Name |
---|---|
81215-6 | Care plan - recommended C-CDA R2.0 and R2.1 sections |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | evolución del problema del paciente: |
es-MX | Spanish (Mexico) | Resultado del problema del paciente: |
fr-BE | French (Belgium) | Problèmes avenir patient: |
it-IT | Italian (Italy) | Paziente, esito problema: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
ru-RU | Russian (Russian Federation) | Пациент проблема исход: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 患者问题结局: Synonyms: 医疗服务对象; |
11348-0 History of Past illness Narrative
Term Description
History of past illness describes the history related to their current complaints, problems, or diagnoses.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Past illness
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Past illness
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- 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
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
92576-8 | Maternal discharge summary - recommended IHE set |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Anamnese früherer Krankheiten: |
es-AR | Spanish (Argentina) | antecedentes de enfermedades pasadas: |
es-MX | Spanish (Mexico) | Enfermedad pasada: |
fr-BE | French (Belgium) | Anamnèse. Maladies antérieures: |
it-IT | Italian (Italy) | Malattie pregresse: Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia; |
nl-NL | Dutch (Netherlands) | ziektegeschiedenis: Synonyms: anamnese |
ru-RU | Russian (Russian Federation) | История предыдущих заболеваний: Synonyms: Анамнез заболеваний История Описательный Точка во времени; |
zh-CN | Chinese (China) | 既往病史: Synonyms: 医疗服务对象; |
10164-2 History of Present illness Narrative
Term Description
History of present illness describes the history related to the reason for a given procedure. It contains the historical details leading up to and pertaining to the patient's current complaint or reason for seeking medical care. Because history of present illness can include past surgical history and other procedures, the Procedure History section may be included under the History of Present Illness section or it may stand alone as its own section.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Present illness
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Pres illness
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
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Anamnese der aktuellen Krankheit: |
es-AR | Spanish (Argentina) | antecedentes de la enfermedad actual: |
es-MX | Spanish (Mexico) | Enfermedad presente: |
it-IT | Italian (Italy) | Malattia attuale: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
nl-NL | Dutch (Netherlands) | huidige ziekte: Synonyms: anamnese |
zh-CN | Chinese (China) | 现有疾病: Synonyms: 医疗服务对象; |
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
Additional Names
- Short Name
- Hospital consultations Doc
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.67
- 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
LOINC | Long Common Name |
---|---|
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | interconsultas hospitalarias: |
es-MX | Spanish (Mexico) | Consultas hospitalarias: |
it-IT | Italian (Italy) | Consulti ospedalieri: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | ziekenhuisbezoeken: |
pt-BR | Portuguese (Brazil) | Consultas hospitalares: Synonyms: Hosp; |
ru-RU | Russian (Russian Federation) | Госпитальные консультации: Synonyms: Документ Точка во времени; |
zh-CN | Chinese (China) | 医院会诊: Synonyms: 临床文档型; |
8648-8 Hospital course Narrative
Term Description
Hospital course describes the sequence of events from admission to discharge in a hospital facility.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Hospital course
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hospital course
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0h(3)
- Last Updated
- Version 2.63
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
57083-8 | Labor and Delivery record panel |
92576-8 | Maternal discharge summary - recommended IHE set |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | curso hospitalario: |
es-MX | Spanish (Mexico) | Curso hospitalario: |
fr-BE | French (Belgium) | Séjour hospitalier: |
it-IT | Italian (Italy) | Decorso ospedaliero: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | ziekenhuis verloop: |
pt-BR | Portuguese (Brazil) | Curso do hospital: Synonyms: Hosp; |
ru-RU | Russian (Russian Federation) | Госпитальный курс: Synonyms: Курс лечения в стационаре Описательный Точка во времени; |
zh-CN | Chinese (China) | 医院病程: Synonyms: 医疗服务对象; |
8653-8 Hospital Discharge instructions
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Discharge instructions
- Property
- Find
- Time
- Pt
- System
- Hospital
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Hosp Discharge instruct
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0h(3)
- Last Updated
- Version 2.67
- Change Reason
- Updated term to represent the current 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
Member of these Panels
LOINC | Long Common Name |
---|---|
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
59271-7 | Hospital discharge summary panel |
Member of these Groups Get Info
LOINC Group | Group Name |
---|---|
LG38843-5 | Discharge instructions| |
LG41829-9 | Hospital| |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Entlassungsanweisungen: |
es-AR | Spanish (Argentina) | instrucciones para el alta del hospital: |
es-MX | Spanish (Mexico) | Instrucciones de descarga: |
it-IT | Italian (Italy) | Istruzioni di dimissione: Synonyms: Documentazione dell''ontologia Istruzioni al momento della dimissione Osservazione Punto nel tempo (episodio) Ruolo non specificato |
nl-NL | Dutch (Netherlands) | ontslagaanwijzingen: |
pt-BR | Portuguese (Brazil) | Instruções de alta hospitalar: Synonyms: Hosp; |
zh-CN | Chinese (China) | 出院指导: Synonyms: 临床文档型; |
10184-0 Hospital discharge physical findings Narrative
Term Description
Hospital discharge physical findings records a narrative description of the patient's physical findings.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Hospital discharge physical findings
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hospital discharge physical findings
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.63
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
59271-7 | Hospital discharge summary panel |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Krankenhausentlassbefund der körperlichen Untersuchungen: |
es-AR | Spanish (Argentina) | hallazgos físicos al momento del alta del hospital: |
es-MX | Spanish (Mexico) | Hallazgos físicos al alta hospitalaria: |
fr-BE | French (Belgium) | Examen physique de sortie hôpital: |
it-IT | Italian (Italy) | Dimissione ospedaliera, osservazioni fisiche: Synonyms: Anamnesi Osservazione Osservazioni fisiche in dimissione ospedaliera paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | ziekenhuis ontslag lichamelijke bevindingen: |
ru-RU | Russian (Russian Federation) | Госпитализация выбытие физикальные находки: Synonyms: Выписка Описательный Точка во времени; |
zh-CN | Chinese (China) | 医院出院体格检查发现: Synonyms: 体格检查(查体、 |
11493-4 Hospital discharge studies summary Narrative
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Hospital discharge studies summary
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hospital discharge studies summary
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
59271-7 | Hospital discharge summary panel |
57083-8 | Labor and Delivery record panel |
92576-8 | Maternal discharge summary - recommended IHE set |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | resumen de los estudios para el alta del hospital: |
es-MX | Spanish (Mexico) | Resumen de estudios de alta hospitalaria: |
fr-BE | French (Belgium) | Résumé des études de sortie hospitalière: |
it-IT | Italian (Italy) | Dimissione ospedaliera, sintesi esami: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) Sintesi esami in dimissione ospedaliera |
nl-NL | Dutch (Netherlands) | ziekenhuis ontslag samenvatting onderzoeken: |
ru-RU | Russian (Russian Federation) | Госпитализация выбытие исследования краткие сведения: Synonyms: Выписка Описательный Точка во времени; |
zh-CN | Chinese (China) | 医院出院检查摘要: Synonyms: 允许...离开(医院、 |
11369-6 History of Immunization Narrative
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Immunization
- Property
- Hx
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Hx of Immunization
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Change Reason
- 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
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-AT | German (Austria) | Synonyms: Immunisierungsstatus |
de-DE | German (Germany) | Impfanamnese: |
es-AR | Spanish (Argentina) | antecedente de inmunización: |
es-MX | Spanish (Mexico) | Inmunización: |
fr-BE | French (Belgium) | Anamnèse. Immunisations: |
it-IT | Italian (Italy) | Immunizzazioni: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
nl-NL | Dutch (Netherlands) | inenting: Synonyms: anamnese vaccinatie |
ru-RU | Russian (Russian Federation) | История иммунизаций: Synonyms: История Описательный Точка во времени; |
zh-CN | Chinese (China) | 疫苗接种史: Synonyms: 免疫接种历史; |
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
Required
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
LOINC | Long Common Name |
---|---|
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
Member of these Groups Get Info
LOINC Group | Group Name |
---|---|
LG41826-5 | {Setting}| |
LG51601-9 | Instructions| |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Instrucciones: |
it-IT | Italian (Italy) | Istruzioni: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
zh-CN | Chinese (China) | 说明: Synonyms: 临床文档型; |
11329-0 History general Narrative - Reported
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- History general
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- Reported
Additional Names
- Short Name
- Hx general 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
- 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 |
---|---|---|
es-AR | Spanish (Argentina) | antecedentes generales: |
es-MX | Spanish (Mexico) | Historia general: |
fr-BE | French (Belgium) | Histoire générale: Synonyms: Anamn?se |
it-IT | Italian (Italy) | Storia generale: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | voorgeschiedenis algemeen: |
ru-RU | Russian (Russian Federation) | История общая: Synonyms: Анамнестические сведения; |
zh-CN | Chinese (China) | 一般病史: Synonyms: 一般史; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- History of medical device use
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Hx medical device use
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.19
- Last Updated
- Version 2.67
- 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
LOINC | Long Common Name |
---|---|
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 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 |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
82811-1 | Nurse summary note - recommended sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Anamnese zum Einsatz von Medizinprodukten: |
es-MX | Spanish (Mexico) | Historial de uso de dispositivos médicos: |
it-IT | Italian (Italy) | Storia di uso di dispositivi medici: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato Strumento medico |
nl-NL | Dutch (Netherlands) | voorgeschiedenis van gebruik van hulpmiddel: |
pt-BR | Portuguese (Brazil) | Histórico da utilização dos dispositivos médicos: Synonyms: ; |
zh-CN | Chinese (China) | 医疗装置使用史: Synonyms: 临床文档型; |
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
Required
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
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
88677-0 | German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Medikationsanamnese: |
es-AR | Spanish (Argentina) | antecedentes de consumo de medicaciones: |
es-MX | Spanish (Mexico) | Uso de medicación: |
fr-BE | French (Belgium) | Anamnèse. Utilsation médications: |
it-IT | Italian (Italy) | Uso di farmaci: Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia; |
nl-NL | Dutch (Netherlands) | medicijngebruik: Synonyms: anamnese geneesmiddelen |
ru-RU | Russian (Russian Federation) | История лекарственный препарат употребления: Synonyms: История Лекарственный анамнез Описательный Точка во времени; |
zh-CN | Chinese (China) | 用药史: Synonyms: 医疗服务对象; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Mental status
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
- Observed
Additional Names
- Short Name
- Mental status
Basic Attributes
- Class
- H&P.PX
- Type
- Clinical
- First Released
- Version 1.0i
- Last Updated
- Version 2.58
Member of these Panels
LOINC | Long Common Name |
---|---|
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | estado mental: |
es-MX | Spanish (Mexico) | Estado mental: |
fr-BE | French (Belgium) | Status mental: |
it-IT | Italian (Italy) | Stato mentale: Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) |
ru-RU | Russian (Russian Federation) | Психический статус: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 心理状况: Synonyms: 体格检查小节与指标; |
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
Required
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
LOINC | Long Common Name |
---|---|
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Dieta y nutricion: |
fr-FR | French (France) | Régime et alimentation: |
it-IT | Italian (Italy) | Dieta e nutrizione: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | dieet en voeding: |
ru-RU | Russian (Russian Federation) | Диета и питание: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 膳食与营养: Synonyms: 医疗服务对象; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Payment sources
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
Additional Names
- Short Name
- Payment sources Doc
Basic Attributes
- Class
- DOC.MISC
- Type
- Clinical
- First Released
- Version 2.21
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
Member of these Panels
LOINC | Long Common Name |
---|---|
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 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 |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-MX | Spanish (Mexico) | Fuentes de pago: |
it-IT | Italian (Italy) | Risorse di pagamento: Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio) |
ru-RU | Russian (Russian Federation) | Оплата источник: Synonyms: Документ Точка во времени; |
zh-CN | Chinese (China) | 款项来源: Synonyms: 临床文档型; |
29545-1 Physical findings Narrative
Observation Required in Panel
Required
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
LOINC | Long Common Name |
---|---|
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
82315-3 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | hallazgos físicos: |
es-MX | Spanish (Mexico) | Hallazgos físicos: |
fr-BE | French (Belgium) | Examen physique: |
it-IT | Italian (Italy) | Osservazioni fisiche: Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | lichamelijke bevindingen: |
pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Физикальные находки: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 体格检查发现: Synonyms: 体格检查(查体、 |
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
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
LOINC | Long Common Name |
---|---|
57082-0 | Antepartum record panel |
69459-6 | Care record summary panel |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
74449-0 | Patient plan of care - recommended IHE set |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Problemliste: |
es-AR | Spanish (Argentina) | lista de problemas: |
es-MX | Spanish (Mexico) | Lista de problemas: |
fr-CA | French (Canada) | Liste des problèmes: |
fr-BE | French (Belgium) | Liste de problèmes: |
it-IT | Italian (Italy) | Lista dei problemi: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | probleemlijst: |
pt-BR | Portuguese (Brazil) | Lista de problemas: Synonyms: Finding; |
ru-RU | Russian (Russian Federation) | Проблем список: Synonyms: Анамнестические сведения; |
zh-CN | Chinese (China) | 问题列表: Synonyms: 分类型应答; |
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.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- History of procedures
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Procedures Hx Doc
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 2.19
- Last Updated
- Version 2.63
- 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
LOINC | Long Common Name |
---|---|
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Anamnese der Prozeduren oder Maßnahmen: |
es-MX | Spanish (Mexico) | Historia de los procedimientos: |
it-IT | Italian (Italy) | Storia di Procedure: Synonyms: Anamnesi Osservazione Punto nel tempo (episodio) Ruolo non specificato |
nl-NL | Dutch (Netherlands) | voorgeschiedenis met verrichtingen: Synonyms: procedures in anamnese |
pt-BR | Portuguese (Brazil) | Histórico de procedimentos: Synonyms: ; |
zh-CN | Chinese (China) | 操作史: Synonyms: 临床文档型; |
29299-5 Reason for visit Narrative
Term Description
This section records the patient's reason for their visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Source: Regenstrief LOINC
Observation Required in Panel
Required
Fully-Specified Name
- Component
- Reason for visit
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Nar
- Method
Additional Names
- Short Name
- Reason for visit
Basic Attributes
- Class
- H&P.HX
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.63
Member of these Panels
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | motivo de la consulta: |
es-MX | Spanish (Mexico) | Razón de la visita: |
fr-CA | French (Canada) | Raison de visite: |
fr-BE | French (Belgium) | Raison de consultation: |
it-IT | Italian (Italy) | Motivo della visita: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | reden voor bezoek: |
pt-BR | Portuguese (Brazil) | Motivo da visita: Synonyms: Finding; |
ru-RU | Russian (Russian Federation) | Причина визит: Synonyms: Описательный Причина визита Точка во времени; |
zh-CN | Chinese (China) | 关于就诊的原因: Synonyms: 关于就诊的理由; |
30954-2 Relevant diagnostic tests/laboratory data Narrative
Observation Required in Panel
Required
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
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
81242-0 | Enhanced discharge summary - recommended CDP Set 1 R1.0 sections |
81615-7 | Enhanced discharge summary - recommended CDP Set 1 R1.1 sections |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
57083-8 | Labor and Delivery record panel |
92574-3 | Labor and delivery summary - recommended IHE set |
92576-8 | Maternal discharge summary - recommended IHE set |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
102087-4 | Secretin stimulation/Gastrin XXX challenge panel |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
55140-8 | Vaccine Adverse Event Reporting System (VAERS) panel |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Relevante diagnostische Tests &oder Labordaten: |
es-AR | Spanish (Argentina) | pruebas diagnósticas relevantes y/o información de laboratorio: |
es-MX | Spanish (Mexico) | Pruebas de diagnóstico o datos de laboratorio relevantes: |
fr-BE | French (Belgium) | Test de diagnostic utiles et données de laboratoire: |
it-IT | Italian (Italy) | Test diagnostici rilevanti &o dati di laboratorio: Synonyms: Osservazione paziente Punto nel tempo (episodio) Test diagnostici rilevanti/dati di laboratorio Vaccinazioni |
nl-NL | Dutch (Netherlands) | relevante diagnostische tests en/of laboratoriumgegevens: |
pt-BR | Portuguese (Brazil) | Testes diagnósticos relevantes e/ou dados laboratóriais: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Значимый диагностический тест &или лабораторные данные: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 相关诊断试验和或实验室数据: Synonyms: 医疗服务对象; |
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
Required
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
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
55169-7 | Data Elements for Emergency Department Systems (DEEDS) Release 1.0 |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
74449-0 | Patient plan of care - recommended IHE set |
59843-3 | Procedure note - recommended C-CDA R1.1 sections |
81217-2 | Procedure note - recommended C-CDA R2.0 and R2.1 sections |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
es-AR | Spanish (Argentina) | revisión de sistemas: |
es-MX | Spanish (Mexico) | Revisión de sistemas: |
fr-BE | French (Belgium) | Revue des systèmes: |
it-IT | Italian (Italy) | Esame di apparati: Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | beoordeling van systemen: |
ru-RU | Russian (Russian Federation) | Исследование по системам: Synonyms: Анамнестические сведения; |
zh-CN | Chinese (China) | 系统评审: Synonyms: 医疗服务对象; |
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
Required
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
LOINC | Long Common Name |
---|---|
69459-6 | Care record summary panel |
81898-9 | Composite triage and nursing note - recommended IHE set |
72231-4 | Consultation note - recommended C-CDA R1.1 sections |
81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections |
72232-2 | Continuity of Care Document - recommended C-CDA R1.1 sections |
81214-9 | Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections |
48769-4 | Continuity of Care panel |
55168-9 | Data Elements for Emergency Department Systems (DEEDS) Release 1.1 |
72229-8 | Discharge summary - recommended C-CDA R1.1 sections |
81219-8 | Discharge summary - recommended C-CDA R2.0 sections |
81218-0 | Discharge summary - recommended C-CDA R2.1 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 |
81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections |
72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections |
81245-3 | Interval document - recommended CDP Set 1 R1.0 and R1.1 sections |
92575-0 | Labor and delivery admission history and physical - recommended IHE set |
57083-8 | Labor and Delivery record panel |
82315-3 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections |
84429-0 | Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set |
82811-1 | Nurse summary note - recommended sections |
82308-8 | Oncology plan of care and summary - recommended CDA R1.2 sections |
74293-2 | Oncology plan of care and summary - recommended CDA set |
72225-6 | Progress note - recommended C-CDA R1.1 sections |
81216-4 | Progress note - recommended C-CDA R2.0 and R2.1 sections |
81223-0 | Referral note - recommended C-CDA R2.0 and R2.1 sections |
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections |
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections |
Language Variants Get Info
Tag | Language | Translation |
---|---|---|
de-DE | German (Germany) | Vitalparameter: |
es-MX | Spanish (Mexico) | Signos vitales: |
es-AR | Spanish (Argentina) | hallazgos físicos: |
fr-BE | French (Belgium) | Signes vitaux: |
it-IT | Italian (Italy) | Segni vitali: Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) |
nl-NL | Dutch (Netherlands) | vitale functies: |
pt-BR | Portuguese (Brazil) | Achados físicos: Synonyms: ; |
ru-RU | Russian (Russian Federation) | Жизненно важные функции: Synonyms: Описательный Точка во времени; |
zh-CN | Chinese (China) | 生命体征: Synonyms: 体格检查小节与指标; |