10154-3 Chief complaint

Term Description

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

Fully-Specified Name

Component

Chief complaint

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Additional Names

Short Name

Chief complaint Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

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

29299-5 Reason for visit

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

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

Language Variants Get Info

Related Names

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

11459-5 Mode of arrival

Fully-Specified Name

Component

Transport mode

Property

Type

Time

Pt

System

EMS system

Scale

Nom

Method

Additional Names

Short Name

Transport mode EMS Sys

Basic Attributes

Class

ED

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.63

Example Answer List LL483-9

Member of these Panels

Language Variants Get Info

Related Names

• DEEDS
• Emergency Department
• EMERGENCY DEPARTMENT (DEEDS)
• Emergency Medical Service(s)
• EMS
• NEMSIS
• Nominal
• Point in time
• Random
• Typ

10164-2 History of present illness

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

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

Language Variants Get Info

Related Names

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

11348-0 History of past illness

Term Description

History of past illness describes the history related to their current complaints, problems, or diagnoses.
Source: Regenstrief LOINC

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

Language Variants Get Info

Related Names

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

10167-5 List of Surgeries

Fully-Specified Name

Component

Surgical procedures

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Surg proc

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.73

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;

Common Test Rank Get Info

18927

Member of these Panels

Language Variants Get Info

Related Names

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

11369-6 Immunizations

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

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

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Immunization status
• Narrative
• P prime
• Point in time
• Random
• Report
• Vaccination
• Vaccinations
• Vaccine

10157-6 Family history

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

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

Language Variants Get Info

Related Names

• Fam Mem
• Family member diseases Hx
• H/O
• H+P
• H+P.HX
• History
• Hx
• Narrative
• P prime
• Point in time
• Random
• Report

29762-2 Social history

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

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

Language Variants Get Info

Related Names

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

10162-6 History of pregnancies

Fully-Specified Name

Component

History of pregnancies

Property

Hx

Time

Pt

System

Reproductive system

Scale

Nar

Method

Additional Names

Short Name

Pregnancies Hx

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Change Reason

Previous Releases: Changed Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• Gestation
• Gestations
• Gravida
• H/O
• H+P
• H+P.HX
• History
• Hx
• Narrative
• P prime
• Point in time
• Pregnancies Hx
• Pregnancy
• Random
• Report

10160-0 Current medications

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

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Medication use

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

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

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Additional Names

Short Name

Allergies &or adverse reactions Doc

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73

Change Reason

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

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

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

11283-9 Acuity assessment

Fully-Specified Name

Component

Acuity assessment

Property

Fcn

Time

Enctr^frst

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Acuity assess 1st enctr

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.73

Change Reason

Previous Releases: Changed answer list from "Normative" to "Preferred" to fit the current LOINC model.;

Common Test Rank Get Info

241

Preferred Answer List LL486-2

Member of these Panels

Language Variants Get Info

Related Names

• 1st
• CLIN
• Encounter
• Function
• Nominal

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

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

Fully-Specified Name

Component

Vital signs

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Observed

Additional Names

Short Name

Vital signs

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.73

Common Test Rank Get Info

576

Member of these Panels

Language Variants Get Info

Related Names

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

51848-0 Assessments

Fully-Specified Name

Component

Evaluation note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Eval note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.73

Change Reason

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

Order vs. Observation

Both

Common Test Rank Get Info

6628

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

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

47420-5 Functional status assessments

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

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

Member of these Groups Get Info

Language Variants Get Info

Related Names

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

47519-4 Procedures and interventions

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

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

Language Variants Get Info

Related Names

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

18610-6 Medications administered

Fully-Specified Name

Component

Medication.administered

Property

Cmplx

Time

Pt

System

^Patient

Scale

Set

Method

Basic Attributes

Class

ATTACH.MEDS

Type

Claims Attachments

First Released

Version 1.0l

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

• ATTACH
• ATTACH.MEDS
• Complex
• Medication administered
• MEDS
• Point in time
• Random

57072-1 Intravenous fluids administered

Term Description

The intravenous fluids administered section shall contain a narrative description of fluids administered to a patient during the course of an encounter.
Source: Regenstrief LOINC

Reference Information

Fully-Specified Name

Component

Intravenous fluids administered

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

IV fluids administered

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

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

11302-7 ED disposition

Fully-Specified Name

Component

ED discharge disposition

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

ED dc dispo

Basic Attributes

Class

ED

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.66

Change Reason

Previous Releases: ; Updated System from "?" to "^Patient" since this term is meant to represent the disposition of the patient at discharge from an emergency department.

Example Answer List LL1053-9

Member of these Panels

Language Variants Get Info

Related Names

• DEEDS
• Disch
• Discharge location
• Discharge status
• ED dc dispo
• Emergency Department
• EMERGENCY DEPARTMENT (DEEDS)
• Nominal
• Point in time
• Random
• Typ

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.