Version 2.78

48765-2 Allergies and other adverse reactions

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

Optional

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:Befund:Zeitpunkt:^Patient:Dokument:
es-MX Spanish (Mexico) Alergias y reacciones adversas:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Allergie &o reazioni avverse:Osservazione:Pt:^Paziente:Doc:
Synonyms: Allergie e reazioni avverse Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) allergieën en/of allergische reacties:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Аллергии &или неблагоприятные реакции:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 变态反应和或不良反应:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 变态反应与不良反应 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 过敏反应;过敏

42348-3 Coded advanced directives

Term Description

Advance directives contains data defining the patient's direction of care and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. Advance directives contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Advance directives
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Advance directives

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.16
Last Updated
Version 2.67
Change Reason
Previous Releases: Based on Clinical LOINC Committee review at the Feb. 2016 meeting, this term represents a document containing information on a patient's advance directives and any supporting documentation, such as a living will. The term was revised to fit the current LOINC Document Ontology model.;
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel
69459-6 Care record summary panel
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
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
71531-8 ESRD hospitalization panel
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
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}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG51615-9 Advance directives|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Patientenverfügung:Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}
Synonyms: Beachtliche und verbindliche Patientenverfügungen
de-DE German (Germany) Patientenverfügung:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-MX Spanish (Mexico) Directivas avanzadas:Tipo:Punto temporal:{Configuración}:Documento:{Role}
fr-CA French (Canada) Directives médicales anticipée:Observation:Temps ponctuel:{Situation}:Document:{Rôle}
it-IT Italian (Italy) Dichiarazioni anticipate di trattamento:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato Testamenti biologici;Direttive anticipate
nl-NL Dutch (Netherlands) wilsverklaring:bevinding:moment:{instelling}:document:{rol}
pt-BR Portuguese (Brazil) Diretivas avançadas:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
zh-CN Chinese (China) 事前指示类:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 事前指示;事前意愿;事前要求;遗嘱;遗愿 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色

51848-0 Assessment

Observation Required in Panel

Optional

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}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38847-6 Evaluation note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de evaluación:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Valutazione, nota:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) onderzoeksverslag:bevinding:moment:{instelling}:document:{rol}
Synonyms: evaluatieverslag
zh-CN Chinese (China) 评价记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书 评价（评估、测评、评测、评判、评定、判定、评量、核定）记录;评估记录 评估 评定 鉴定

11332-4 Hx of cognitive function

Part Descriptions

LP184337-6   Cognitive function
A patient's cognitive status (e.g., mood, memory, ability to make decisions) and issues that limit cognition (e.g., amnesia, dementia, aggressive behavior). May include assessment scale observations, identify caregivers, and provide information about non-medicinal supplies. Source: HL7 Consolidated CDA

Observation Required in Panel

Optional

Fully-Specified Name

Component
Cognitive function
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Cogn func

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
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
82811-1 Nurse summary note - recommended sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) antecedentes de la función cognitiva:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Función cognitiva:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Funzione cognitiva:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) cognitieve functie:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
zh-CN Chinese (China) 认知功能:历史记录:时间点:^患者:叙述型:
Synonyms: FCN 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 认知机能

11450-4 Active problems

Observation Required in Panel

Optional

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:Befund:Zeitpunkt:^Patient:Nominal:Berichtet
es-AR Spanish (Argentina) lista de problemas:hallazgo:punto en el tiempo:^paciente:Nominal:informado
es-MX Spanish (Mexico) Lista de problemas:Tipo:Punto temporal:^ Paciente:Nominal:Reported
fr-CA French (Canada) Liste des problèmes:Observation:Temps ponctuel:^Patient:Nominal:Rapporté
fr-BE French (Belgium) Liste de problèmes:Observation:Temps ponctuel:^Patient:Nominal:Rapporté
it-IT Italian (Italy) Lista dei problemi:Osservazione:Pt:^Paziente:Nom:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) probleemlijst:bevinding:moment:^patiënt:nominaal:rapportage
pt-BR Portuguese (Brazil) Lista de problemas:Achado:Pt:^Paciente:Nom:Relatado
Synonyms: Finding; Findings; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Проблем список:Находка:ТчкВрм:^Пациент:Ном:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Номинальный;Именной Список проблем Точка во времени;Момент
zh-CN Chinese (China) 问题列表:发现:时间点:^患者:名义型:报告法
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 时刻;随机;随意;瞬间 病史与体格检查 问题目录;问题清单 难题;困难;棘手问题;麻烦;乱子;疑难问题;疑难

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

Optional

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:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Queja principal:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Plainte principale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Disturbo principale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) belangrijkste klacht:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Основная жалоба:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 主诉:发现:时间点:^患者:叙述型:报告法
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 控诉;申诉;指控;不平;牢骚;委屈;意见;怨言;病痛;主诉 时刻;随机;随意;瞬间 病史与体格检查

46241-6 Hospital adm diagnosis

Observation Required in Panel

Optional

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:Interpretación:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Documents admission hôpital:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Ricovero ospedaliero, Dx:Imp:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Diagnosi di ricovero ospedaliero;Diagnosi di ammis Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis opnamediagnose:interpretatie:moment:^patiënt:tekstueel:rapportage
pt-BR Portuguese (Brazil) Admissão hospitalar Dx:Imp:Pt:^Paciente:Nar:Relatado
Synonyms: Hosp; Interpretation; Interp; Impression; Impressions; Point in time; Random; Narrative; Report; Diagnosis
ru-RU Russian (Russian Federation) Госпитализация Dx:Впчт:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Впечатление/интерпретация исследования Диагноз госпитализации Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院入院诊断:印象:时间点:^患者:叙述型:报告法
Synonyms: Dx 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 病院 诊断（Diagnosis，Dx） 院

11535-2 Discharge diagnosis

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

Optional

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:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Alta hospitalaria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Documents sortie hôpital:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, Dx:Imp:Pt:^Paziente:Nar:
Synonyms: Anamnesi Diagnosi di dimissione ospedaliera Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis onslagdiagnose:interpretatie:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Alta hospitalar Dx:Imp:Pt:^Paciente:Nar:
Synonyms: Hosp; Interpretation; Interp; Impression; Impressions; Point in time; Random; Narrative; Report; Diagnosis
ru-RU Russian (Russian Federation) Госпитализация выбытие Dx:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Выписка Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院诊断:印象:时间点:^患者:叙述型:
Synonyms: Dx 允许...离开(医院、军队);(从监狱)释放 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查 病院 诊断（Diagnosis，Dx） 院

46264-8 Medical devices

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

Optional

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:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-MX Spanish (Mexico) Historial de uso de dispositivos médicos:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Storia di uso di dispositivi medici:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato Strumento medico
nl-NL Dutch (Netherlands) voorgeschiedenis van gebruik van hulpmiddel:bevinding:moment:{instelling}:document:{rol}
pt-BR Portuguese (Brazil) Histórico da utilização dos dispositivos médicos:Achado:Pt:{Fixação}:Doc:{Fornecedor}
Synonyms: ; Medical device use Hx; Finding; Findings; Point in time; Random
zh-CN Chinese (China) 医疗装置使用史:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 医疗器材;医疗设备;医疗卫生器材 医疗装置使用历史;医学装置使用史;医疗器材使用史;医疗设备使用史;医疗卫生器材使用史 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 未加明确说明的角色 杂项;杂项类;杂项试验

30954-2 Coded results

Observation Required in Panel

Optional

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:Befund:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) pruebas diagnósticas relevantes y/o información de laboratorio:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Pruebas de diagnóstico o datos de laboratorio relevantes:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Test de diagnostic utiles et données de laboratoire:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Test diagnostici rilevanti &o dati di laboratorio:Osservazione:Pt:^Paziente:Nar:
Synonyms: Osservazione paziente Punto nel tempo (episodio) Test diagnostici rilevanti/dati di laboratorio Vaccinazioni
nl-NL Dutch (Netherlands) relevante diagnostische tests en/of laboratoriumgegevens:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Testes diagnósticos relevantes e/ou dados laboratóriais:Achado:Pt:^Paciente:Nar:
Synonyms: ; Relevant Dx tests/lAc data; Finding; Findings; Point in time; Random; Narrative; Report; VACCINE
ru-RU Russian (Russian Federation) Значимый диагностический тест &или лабораторные данные:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 相关诊断试验和或实验室数据:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 接种;接种记录;疫苗;疫苗接种 时刻;随机;随意;瞬间 检验科;化验室;化验科 相关诊断试验/实验室数据;相关诊断试验和或实验室资料;相关诊断试验和或实验室检验数据;相关诊断试验和或检验数据;相关诊断试验和或化验数据

18610-6 Medications (administered)

Observation Required in Panel

Optional

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

LOINC Long Common Name
57082-0 Antepartum record panel
81898-9 Composite triage and nursing note - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82811-1 Nurse summary note - recommended sections
74449-0 Patient plan of care - recommended IHE set

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) medicación.administrada:complejo:punto en el tiempo:^paciente:Conjunto:
fr-FR French (France) Traitement administré:Autre:Ponctuel:Patient:Statut:
it-IT Italian (Italy) Farmaco.somminstrato:Cmplx:Pt:^Paziente:Determinato:
Synonyms: Allegato Allegato farmaci Complesso paziente Punto nel tempo (episodio) Stabilito;Fissato
nl-NL Dutch (Netherlands) toegediende medicatie:complex:moment:^patiënt:set:
Synonyms: geneesmiddelen
ru-RU Russian (Russian Federation) Лекарственный препарат.введённый:Кмплкс:ТчкВрм:^Пациент:Множество:
Synonyms: Комплекс Лекарство введено Точка во времени;Момент
zh-CN Chinese (China) 药物.已施用的:复合型属性:时间点:^患者:集合型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.药物处理;健康保险便携与责任法案信息附件.药物处理;健康保险便携与责任法案信息附件.药物治疗;药物处理HIPAA信息附件;药物处理信息附件;药物处理健康保险便携与责任法案信息附件 临床信息附件集;临床信息附件集合;集;集合 信息附件;健康保险便携与责任法案信息附件;附件 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 处理用药.已施用的;处理用药.已服用的;处理用药.已给予的;处理用药物.已施用的;处理用药物.已服用的;处理用药物.已给予的;处理药物.已施用的;处理药物.已服用的;处理药物.已给予的;已施用的处理药物;已施用的治疗药物;已服用的处理药物;已服用的治疗药物;已给予的处理药物;已给予的治疗药物;治疗用药.已施用的;治疗用药.已服用的;治疗用药.已给予的;治疗用药物.已施用的;治疗用药物.已服用的;治疗用药物.已给予的;治疗药物.已服用的;治疗药物.已给予的;治疗药物.已施用的;治疗药物.已服用的;治疗药物. 处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 复合属性;复杂型属性;复杂属性 所施用的药物;已使用的药物;已使用的处理用药;已使用的处理用药物;已使用的处理药物;已使用的治疗用药;已使用的治疗用药物;已使用的用药;已使用的药物处理;已使用的药物治疗;已使用的治疗药物 时刻;随机;随意;瞬间 药物;药物处理;用药;使用药物

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

Observation Required in Panel

Optional

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:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-MX Spanish (Mexico) Historia de los procedimientos:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Storia di Procedure:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Anamnesi Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) voorgeschiedenis met verrichtingen:bevinding:moment:{instelling}:document:{rol}
Synonyms: procedures in anamnese
pt-BR Portuguese (Brazil) Histórico de procedimentos:Achado:Pt:{Fixação}:Doc:{Fornecedor}
Synonyms: ; Procedures Hx; Finding; Findings; Point in time; Random
zh-CN Chinese (China) 操作史:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 操作历史;操作项目历史;操作项目史 时刻;随机;随意;瞬间 未加明确说明的角色 病史与体格检查

38212-7 Pain assessment panel

Observation Required in Panel

Optional

Fully-Specified Name

Component
Pain assessment panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Additional Names

Short Name
Pain Assessment Pnl

Basic Attributes

Class
PANEL.H&P
Type
Clinical
First Released
Version 2.13
Last Updated
Version 2.69
Order vs. Observation
Order
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
57083-8 Labor and Delivery record panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) PAIN ASSESSMENT PANEL:-:punto en el tiempo:^PATIENT:-:
es-MX Spanish (Mexico) Panel de evaluación del dolor:-:Punto temporal:^ Paciente:-:
it-IT Italian (Italy) Dolore, panel valutazione:-:Pt:^Paziente:-:
Synonyms: Panel valutazione del dolore paziente Punto nel tempo (episodio) Set di prescrizione per anamnesi e esame obiettivo Valutazione del dolore
nl-NL Dutch (Netherlands) pijn vaststellingspanel:-:moment:^patiënt:-:
pt-BR Portuguese (Brazil) Avaliação da dor painel:-:Pt:^Paciente:-:
Synonyms: ; Pain Assessment Pnl; Point in time; Random; Pan; Panl
ru-RU Russian (Russian Federation) Боль оценка панель:-:ТчкВрм:^Пациент:-:
Synonyms: Точка во времени;Момент
zh-CN Chinese (China) 疼痛评估组套:-:时间点:^患者:-:
Synonyms: 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.病史与体格检查小节;组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目）.历史纪录与体格检查;医嘱组.历史纪录与体格检查小节;医嘱组.病史与体格检查;历史纪录与体格检查医嘱组;历史纪录与体格检查医嘱组类;历史纪录与体格检查小节医嘱组;历史纪录与体格检查小节医嘱组类;病史与体格检查医嘱组;病史与体格检查医嘱组类;病史与体格检查小节医嘱组;病史与体格检查小节医嘱组类 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 疼;痛;痛苦;悲痛;苦恼 疼痛评估（评价、估计、估价、评论、估定、估算） 疼痛评估（评价、估计、估价、评论、估定、估算）组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目） 病史与体格检查 组 组合 组合医嘱 组合类 组套 评价;估计;估价;评论;估定;估算

46209-3 Provider orders

Observation Required in Panel

Optional

Fully-Specified Name

Component
Provider orders
Property
Find
Time
-
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Provider orders

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.17
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
26443-2 Clinical reports.non lab claims attachment
82811-1 Nurse summary note - recommended sections
74449-0 Patient plan of care - recommended IHE set

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Anforderung:Ergebnis:-:^Patient:Dokument:
Synonyms: Auftrag
es-MX Spanish (Mexico) Órdenes de proveedores:Tipo:-:^ Paciente:Documento:
it-IT Italian (Italy) Provider, ordini:Osservazione:-:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Ordini del care provider Osservazione paziente
pt-BR Portuguese (Brazil) Encomendas ao fornecedor:Achado:-:^Paciente:Doc:
Synonyms: Finding; Findings
ru-RU Russian (Russian Federation) Провайдер заказы:Находка:-:^Пациент:Док:
Synonyms: Документ
zh-CN Chinese (China) 服务提供者医嘱:发现:-:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档.其他;杂项类文档;其他文档 服务提供者（提供方、提供者、服务人员、服务提供方、服务方、服务机构、服务者）医嘱（医令、指示、嘱托、嘱咐） 杂项;杂项类;杂项试验

18776-5 Treatment plan

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

Optional

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}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38745-2 Plan of care note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Behandlungsplan - Notiz:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-AR Spanish (Argentina) plan de tratamiento:hallazgo:punto en el tiempo:plan de tratamiento:Narrativo:
es-MX Spanish (Mexico) Nota del plan de cuidados:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) behandelplan:bevinding:moment:{instelling}:document:{rol}
Synonyms: zorgplan
zh-CN Chinese (China) 医疗服务计划记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 医疗服务（照护服务、护理服务、护理、照护、医疗照护、诊疗、诊疗服务、照顾、看护）计划（方案）记录 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书

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

Optional

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:Befund:Zeitpunkt:^Patient:Freitext:Beobachtet
es-MX Spanish (Mexico) Signos vitales:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:signos vitales:Narrativo:observado
fr-BE French (Belgium) Signes vitaux:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Segni vitali:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) vitale functies:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Sinais vitais:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Жизненно важные функции:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 生命体征:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 生命体征类;生命征象 病史与体格检查 观测法

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

Optional

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:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-FR French (France) Régime et alimentation:Recherche:Ponctuel:Patient:Résultat textuel:
it-IT Italian (Italy) Dieta e nutrizione:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) dieet en voeding:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Диета и питание:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 膳食与营养:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 滋养;营养补给;营养学;食物;营养品 病史与体格检查 饮食;日常饮食;日常食物;规定饮食;食谱 饮食与营养;饮食和营养

61148-3 Fluid management note

Term Description

The description of fluids taken in and put out during the course of an encounter.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Fluid management note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Fluid management note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.34
Last Updated
Version 2.67
Change Reason
Based on Committee review, this term was updated to align with the Document Ontology model since this concept represents a written note or description about fluid management, including intake & output, for an encounter.
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
82811-1 Nurse summary note - recommended sections

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG50103-7 Fluid management note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de gestión de fluidos:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Nota di gestione del fluido:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato
zh-CN Chinese (China) 液体管理记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 液 液体（出入量）管理记录 笔记;按语;注释;说明;票据;单据;证明书