48765-2 Allergies and adverse reactions Document

Term Description

Contains a list and description of any allergies or adverse reactions pertinent to current or past medical history. At a minimum this section should contain currently active and any relevant historical allergies and adverse reactions.

Observation Required in Panel

Required

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73 (MIN)

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

46240-8 History of Hospitalizations+Outpatient visits Narrative

Term Description

History of hospitalizations and History of outpatient visits (i.e. Encounters) lists and describes any healthcare encounters pertinent to the patient's current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient's condition. It may include visits, appointments, as well as non face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment.

Observation Required in Panel

Required

Fully-Specified Name

Component

Hospitalizations+Outpatient visits

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

Change Reason

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

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Hospitalizations+OP visits
• Narrative
• OP
• Outpt visits
• P prime
• Point in time
• Random
• Report

10157-6 History of family member diseases note

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.

Observation Required in Panel

Required

Fully-Specified Name

Component

History of family member diseases note

Property

Hx

Time

Pt

System

^Family member

Scale

Doc

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.81 (NAM)

Change Reason

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

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Fam Mem
• Family member diseases Hx
• H/O
• H+P
• H+P.HX
• History
• Hx
• Hx of fam member ds note
• notes
• P prime
• Point in time
• Random
• Visit note

47420-5 Functional Status Assessment Note

Term Description

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

Observation Required in Panel

Required

Fully-Specified Name

Component

Functional status assessment note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.67 (MIN)

Change Reason

Previous Releases: Based on Clinical LOINC Committee approval on 2/17/2012, "note" was added to the Component as the Kind of Document.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;

Order vs. Observation

Both

HL7^® Attachment Structure

No IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

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

10160-0 History of Medication use Narrative

Term Description

History of medication use defines a patient's current medications and history of pertinent medications. This term may also include a patient's prescription and dispense history.

Observation Required in Panel

Required

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

61144-2 Diet and nutrition Narrative

Term Description

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

Observation Required in Panel

Required

Fully-Specified Name

Component

Diet and nutrition

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.34

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

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

18776-5 Plan of Care Note

Term Description

Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.

Observation Required in Panel

Required

Fully-Specified Name

Component

Plan of care note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 1.0l

Last Updated

Version 2.67 (MIN)

Change Reason

Previous Releases: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.;

Order vs. Observation

Both

HL7^® Attachment Structure

IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Care plan
• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Treatment plan
• Visit note

11450-4 Problem list - Reported

Observation Required in Panel

Required

Fully-Specified Name

Component

Problem list

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.73 (MIN)

Common Test Rank Get Info

9889

Member of these Panels

Language Variants Get Info

Related Names

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

47519-4 History of Procedures Document

Term Description

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

Observation Required in Panel

Required

Fully-Specified Name

Component

History of procedures

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63 (MIN)

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

30954-2 Relevant diagnostic tests/laboratory data note

Observation Required in Panel

Required

Fully-Specified Name

Component

Relevant diagnostic tests &or laboratory data note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Basic Attributes

Class

VACCIN

Type

Clinical

First Released

Version 2.04

Last Updated

Version 2.81 (NAM)

Change Reason

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

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

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

8716-3 Vital signs note

Term Description

The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included.

Observation Required in Panel

Required

Fully-Specified Name

Component

Vital signs note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.81 (NAM)

Change Reason

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

Common Test Rank Get Info

576

Member of these Panels

Language Variants Get Info

Related Names

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