Version 2.77

55752-0 Clinical information

Term Description

A section containing clinical details about the case such as presenting signs and symptoms, onset date of symptoms, the specific diagnosis/condition names (e.g Ulceroglandular tularemia), who made the diagnosis, their contact information , when the diagnosis was made etc., past clinical hx, the overall condition of the patient, etc.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Clinical information
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Clinical info

Basic Attributes

Class
PUBLICHEALTH
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73
Common Test Rank Get Info
1702

Member of these Panels

LOINC Long Common Name
84908-3 Cancer pathology panel - Prostate cancer
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections
81186-9 Gastric cancer pathology panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Información clínica:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-FR French (France) Informations cliniques:Recherche:Ponctuel:Patient:Résultat textuel:
it-IT Italian (Italy) Informazioni cliniche:Osservazione:Pt:^Paziente:Nar:
Synonyms: Osservazione paziente Punto nel tempo (episodio) Sanità pubblica
ru-RU Russian (Russian Federation) Клиническая информация:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 临床信息:发现:时间点:^患者:叙述型:
Synonyms: 临床资料;临床资讯 公共健康;公众健康;大众健康 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 时刻;随机;随意;瞬间

55115-0 Requested imaging studies information Document

Term Description

Information on requested imaging studies and associated tests. It may include information on the reason for the request.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Requested imaging studies information
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Requested imaging studies info Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73
Order vs. Observation
Both

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

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Información de estudios de imagen solicitados:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Studi di imaging richiesti, informazioni:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Informazioni su studi di imaging richiesti Miscellanea Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Запрошенные визуализация исследования информация:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Информация о запрошенных исследованиях по визуализации Точка во времени;Момент
zh-CN Chinese (China) 已申请成像检查信息: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 已申请成象检查信息;已申请成象技术检查信息;已申请影像学检查信息;已申请显像检查信息;已申请透视显像检查信息;已申请成像检查项目;已申请的成像检查的信息;已请求成像检查信息 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

59768-2 Procedure indications [Interpretation] Narrative

Term Description

The Procedure indications section records details about the reason for the procedure, treatment or service.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Procedure indications
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Procedure indications Imp

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 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
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure 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

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Indicaciones de procedimiento:Interpretación:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura, indicazioni:Imp:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Impressione/interpretazione di studio Indicazioni di procedura Miscellanea paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) indicaties ingreep:interpretatie:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство показания:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作适应症:印象: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 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 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 操作;程序;手续;步骤;规程;程序流程 操作适应症（适应证、指征）;操作适应症;操作项目适应证 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 适应证;指征;适应症类

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

Optional

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:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Historia general:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Histoire générale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
Synonyms: Anamn?se
it-IT Italian (Italy) Storia generale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) voorgeschiedenis algemeen:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) История общая:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Общий анамнез Описательный Точка во времени;Момент
zh-CN Chinese (China) 一般病史:发现:时间点:^患者:叙述型:报告法
Synonyms: 一般史;一般历史;普通历史;普通史;普通病史 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 病史与体格检查

55111-9 Current imaging procedure descriptions Document

Term Description

Contains information on current imaging studies and associated tests.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Current imaging procedure descriptions
Property
Desc
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Current imaging proc desc Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73
Order vs. Observation
Both

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

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Descripciones de los procedimientos de diagnóstico por imágenes actuales:Desc:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Descrizioni attuale procedure di imaging:Desc:Pt:^Paziente:Doc:
Synonyms: Descrizione Descrizioni attuale procedura di diagnostica per i Documentazione miscellanea Miscellanea paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Текущее визуализация вмешательство описания:Опис:ТчкВрм:^Пациент:Док:
Synonyms: Документ Описание Процедура Точка во времени;Момент
zh-CN Chinese (China) 当前成像操作描述:描述: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 当前成像操作项目说明;当前成象操作描述;当前成象技术操作描述;当前影像学操作描述;当前显像操作描述;当前透视显像操作描述;当前成像操作项目描述 操作;程序;手续;步骤;规程;程序流程 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 说明

55109-3 Complications Document

Term Description

Information on additional medical problems that develop following a procedure, diagnostic test or study, treatment, or illness.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Complications
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Complications Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73
Order vs. Observation
Both

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
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
62863-6 PhenX domain - Infectious diseases and immunity
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure 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

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Complicaciones:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Complicazioni:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) complicaties:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Осложнения:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 并发症: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 合并症 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

73569-6 Radiation exposure and protection information [Description] Document Diagnostic imaging

Term Description

The Radiation Exposure and Protection Information section contains information related to radiation exposure and protection of the patient based on current national legal requirements or standards. The section describes the indication for the treatment/procedure (e.g. fracture of tibia), relevant status of a patient (e.g. pregnancy status), who authorized the radiation treatment, the protection provided, such as lead apron, for a specific body part, and the amount, type and route of radioactive substance administered.
Source: Regenstrief LOINC

Observation Required in Panel

Conditional

Fully-Specified Name

Component
Radiation exposure and protection information
Property
Desc
Time
Pt
System
^Patient
Scale
Doc
Method
Diagnostic imaging

Additional Names

Short Name
Rad expo+protect info Doc Dx Imaging

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.44
Last Updated
Version 2.63
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Información sobre exposición y protección a la radiación:Desc:Punto temporal:^ Paciente:Documento:Diagnostic imaging
it-IT Italian (Italy) Esposizione alle radiazioni e informazione sulla protezione:Desc:Pt:^Paziente:Doc:Imaging diagnostico
Synonyms: Descrizione Documentazione miscellanea Miscellanea paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 辐射暴露与防护信息:描述:时间点:^患者:文档型:诊断成像
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 图像诊断;影像学诊断;影像诊断;影像诊断技术;诊断影像学;诊断显像 成象;成象技术;影像学;显像;透视显像 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 曝光 杂项;杂项类;杂项试验 诊断 说明 辐射;放射治疗;放疗;放射疗法;辐射治疗 辐射暴露与防护（保护）信息;辐射暴露和防护信息;放射暴露与防护信息 辐照 防护

18834-2 Radiology Comparison study (narrative)

Observation Required in Panel

Optional

Fully-Specified Name

Component
Comparison.study
Property
Imp
Time
Pt
System
XXX
Scale
Nar
Method
Radiology

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
85430-7 Diagnostic imaging report - example sections and entries
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

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) estudio.comparativo:impresión/interpretación del estudio:punto en el tiempo:XXX:Narrativo:radiología
it-IT Italian (Italy) Confronto.studio:Imp:Pt:XXX:Nar:Radiologia
Synonyms: Allegato Allegato referto clinico Impressione/interpretazione di studio Punto nel tempo (episodio) Studio comparativo
nl-NL Dutch (Netherlands) vergelijkend onderzoek:interpretatie:moment:XXX:tekstueel:radiologie
pt-BR Portuguese (Brazil) Estudo.comparativo:Imp:Pt:XXX:Nar:Radiologia
Synonyms: Interpretation; Interp; Impression; Impressions; Point in time; Random; Misc; Miscellaneous; Unspecified; Other; Narrative; Report; Compare
zh-CN Chinese (China) 比较.检查:印象:时间点:XXX:叙述型:放射医学
Synonyms: 不明的;其他;将在相应消息内其他部分之中加以详细说明;未作详细说明的;未作说明的;未做说明的标本;未加规定的;未加说明的标本;杂项 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 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 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 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 时刻;随机;随意;瞬间 检查分析 比较.研究 研究;检查项目;调查;考察;研究项目;学习 考察 调查

59776-5 Procedure findings Narrative

Term Description

The Procedure findings section records clinically significant observations confirmed or discovered during a procedure, treatment or service.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Procedure findings
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Findings

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 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
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure 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

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos del procedimiento:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura, osservazioni:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Osservazione Osservazioni su procedura paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ingreep bevindingen:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство находки:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作发现: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 操作;程序;手续;步骤;规程;程序流程 操作项目发现;操作所见;操作项目所见 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

76514-9 Fetal Narrative Study observation general Diagnostic imaging

Term Description

The fetal study observation section contains the fetal ID (i.e. name, such as "Fetus A") along with the clinically significant observations (e.g. estimated gestational age) confirmed or discovered during an imaging procedure.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Study observation.general
Property
Find
Time
Pt
System
^Fetus
Scale
Nar
Method
Diagnostic imaging

Additional Names

Short Name
Dx Imaging Fetus Study

Basic Attributes

Class
OB.US
Type
Clinical
First Released
Version 2.52
Last Updated
Version 2.63
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Observación del estudio general:Tipo:Punto temporal:^ Feto:Narrativo:Diagnostic imaging
it-IT Italian (Italy) Rilievo.generale:Osservazione:Pt:^feto:Nar:Imaging diagnostico
Synonyms: Ecografia ostetrica Osservazione Osservazione di studio Osservazione di studio generale Punto nel tempo (episodio)
zh-CN Chinese (China) 检查观察结果.一般性:发现:时间点:^胎儿:叙述型:诊断成像
Synonyms: 产科 产科.超声;产科.超声.印象与测量指标;产科学.超声;产科学.超声.印象与测量指标;产科学检查与测量指标.超声.印象与测量指标;产科学超声印象与测量指标 产科学 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 图像诊断;影像学诊断;影像诊断;影像诊断技术;诊断影像学;诊断显像 成象;成象技术;影像学;显像;透视显像 时刻;随机;随意;瞬间 检查;检查观察 检查分析 检查观察结果.一般;一般性检查观察;一般性检查观察结果;检查观察.一般性;检查观察结果.大体;检查观察结果.综合 研究;检查项目;调查;考察;研究项目;学习 考察 胎;超系统 - 胎儿 诊断 调查

19005-8 Radiology Imaging study [Impression] (narrative)

Observation Required in Panel

Required

Fully-Specified Name

Component
Imaging study
Property
Imp
Time
Pt
System
XXX
Scale
Nar
Method
Radiology

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
85430-7 Diagnostic imaging report - example sections and entries
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

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) impresión de rayos X:impresión/interpretación del estudio:punto en el tiempo:XXX:Narrativo:radiología
it-IT Italian (Italy) Studio di imaging:Imp:Pt:XXX:Nar:Radiologia
Synonyms: Allegato Allegato referto clinico Impressione/interpretazione di studio Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) beeldvormend onderzoek:interpretatie:moment:XXX:tekstueel:radiologie
pt-BR Portuguese (Brazil) Estudo radiológico:Imp:Pt:XXX:Nar:Radiologia
Synonyms: Interpretation; Interp; Impression; Impressions; Point in time; Random; Misc; Miscellaneous; Unspecified; Other; Narrative; Report
zh-CN Chinese (China) 成像检查:印象:时间点:XXX:叙述型:放射医学
Synonyms: 不明的;其他;将在相应消息内其他部分之中加以详细说明;未作详细说明的;未作说明的;未做说明的标本;未加规定的;未加说明的标本;杂项 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 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 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 成象检查;成象技术检查;影像学检查;显像检查;透视显像检查;成像检查项目 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 时刻;随机;随意;瞬间 检查分析 研究;检查项目;调查;考察;研究项目;学习 考察 调查

73568-8 Communication of critical results [Description] Document

Term Description

The Communication of Critical Results section includes notification to health care providers of critical or discrepant findings for a patient. The section describes the specific finding, whether it is critical or discrepant, how it was communicated (personally or notified by another approved mode of communication for critical results), who (e.g. name of reporting radiologist) communicated the findings, to whom (e.g. name of requesting provider) and when (date and time). The section also states the level of urgency (Red, Orange, Yellow, or not urgent) for the critical or discrepant result. Red indicates the finding is potentially immediately life-threatening, Orange indicates it could result in mortality/morbidity within 2-3 days, and Yellow indicates it could eventually result in mortality or morbidity if not treated.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Communication of critical results
Property
Desc
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Comm critical results Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.44
Last Updated
Version 2.63
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Comunicación de resultados críticos:Desc:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Comunicazione dei risultati critici:Desc:Pt:^Paziente:Doc:
Synonyms: Descrizione Documentazione miscellanea Miscellanea paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Информация о критических результатах:Опис:ТчкВрм:^Пациент:Док:
Synonyms: Документ Описание Точка во времени;Момент
zh-CN Chinese (China) 危急结果的沟通与交流:描述: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 危急（危重、关键、重要）结果的沟通与交流（沟通交流、沟通、交流、交流与沟通、通讯、传输） 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 说明

55113-5 Key images Document Radiology

Term Description

List of references to images considered significant.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Key images
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method
Radiology

Additional Names

Short Name
Key images Doc Radiology

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73
Order vs. Observation
Both

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

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Schlüsselbilder:Ergebnis:Zeitpunkt:^Patient:Dokument:Radiologie
Synonyms: KOS Objekte
es-MX Spanish (Mexico) Imágenes clave:Tipo:Punto temporal:^ Paciente:Documento:Radiology
it-IT Italian (Italy) Immagini chiave:Osservazione:Pt:^Paziente:Doc:Radiologia
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) sleutelbeelden:bevinding:moment:^patiënt:document:radiologie
zh-CN Chinese (China) 关键图像:发现:时间点:^患者:文档型:放射医学
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 关键图象;关键图片;关键图形 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 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 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

18783-1 Radiology Study recommendation (narrative)

Observation Required in Panel

Optional

Fully-Specified Name

Component
Study recommendation
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method
Radiology

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
85430-7 Diagnostic imaging report - example sections and entries
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

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) recomendación del estudio:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:radiología
it-IT Italian (Italy) Raccomandazione studio:Imp:Pt:^Paziente:Nar:Radiologia
Synonyms: Allegato Allegato referto clinico Consiglio Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) onderzoek aanbeveling:interpretatie:moment:^patiënt:tekstueel:radiologie
zh-CN Chinese (China) 检查建议:印象:时间点:^患者:叙述型:放射医学
Synonyms: 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 信息附件;健康保险便携与责任法案信息附件;附件 劝告;介绍;推荐;介绍信 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 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 放射学;放射科;放射线学;X射线学;影像诊断学;放射;X光线学;X光线科;应用辐射学;辐射学 时刻;随机;随意;瞬间 检查分析 检查项目建议;检查劝告;检查推荐 研究;检查项目;调查;考察;研究项目;学习 考察 调查

55107-7 Addendum Document

Term Description

Supplementary information or an appendix added to the original document contents.
Source: Regenstrief LOINC

Observation Required in Panel

Conditional

Fully-Specified Name

Component
Addendum
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Addendum Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
4616

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

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anhang:Befund:Zeitpunkt:^Patient:Dokument:
es-ES Spanish (Spain) Adenda:Hallazgo:Punto temporal:^paciente:Doc:
es-MX Spanish (Mexico) Apéndice:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Appendice:Osservazione:Pt:^Paziente:Doc:
Synonyms: Aggiunta Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) addendum:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Дополнение:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Аддендум Документ Точка во времени;Момент
zh-CN Chinese (China) 补遗: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 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 附录;补充;附件

73568-8 Communication of critical results [Description] Document

Term Description

The Communication of Critical Results section includes notification to health care providers of critical or discrepant findings for a patient. The section describes the specific finding, whether it is critical or discrepant, how it was communicated (personally or notified by another approved mode of communication for critical results), who (e.g. name of reporting radiologist) communicated the findings, to whom (e.g. name of requesting provider) and when (date and time). The section also states the level of urgency (Red, Orange, Yellow, or not urgent) for the critical or discrepant result. Red indicates the finding is potentially immediately life-threatening, Orange indicates it could result in mortality/morbidity within 2-3 days, and Yellow indicates it could eventually result in mortality or morbidity if not treated.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Communication of critical results
Property
Desc
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Comm critical results Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.44
Last Updated
Version 2.63
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Comunicación de resultados críticos:Desc:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Comunicazione dei risultati critici:Desc:Pt:^Paziente:Doc:
Synonyms: Descrizione Documentazione miscellanea Miscellanea paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Информация о критических результатах:Опис:ТчкВрм:^Пациент:Док:
Synonyms: Документ Описание Точка во времени;Момент
zh-CN Chinese (China) 危急结果的沟通与交流:描述: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 危急（危重、关键、重要）结果的沟通与交流（沟通交流、沟通、交流、交流与沟通、通讯、传输） 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 说明