89215-8
Gynecology Admission history and physical note
Active
Part Descriptions
LP32899-4 Gynecology
Gynaecology or gynecology (see spelling differences) literally means 'the science of women', but in medicine this is the specialty of diseases of the female reproductive system (uterus, vagina and ovaries). Almost all modern gynaecologists are also obstetricians ; see Obstetrics and gynaecology.
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Source: Wikipedia, Gynecology (Wikipedia)
LP32899-4 Gynecology
A medical-surgical specialty concerned with the physiology and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology.
Source: National Library of Medicine, MeSH 2006
Fully-Specified Name
- Component
- Admission history and physical note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Gynecology
Additional Names
- Short Name
- Gynecology Admit H&P note
Associated Observations
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
This panel contains the recommended sections for history and physical notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 72228-0 | History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections | |||
| Indent48765-2 | Alerts | R | ||
| Indent51848-0 | Assessment | R | ||
| Indent51847-2 | Assessment+Plan | R | ||
| Indent10154-3 | Chief complaint | R | ||
| Indent10157-6 | Family history | R | ||
| Indent10210-3 | General status | R | ||
| Indent10164-2 | History of present illness | O | ||
| Indent11369-6 | History of immunizations | O | ||
| Indent69730-0 | Instructions | O | ||
| Indent10160-0 | Medications | R | ||
| Indent11348-0 | Past medical history | R | ||
| Indent29545-1 | Physical examination | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent11450-4 | Problems | O | ||
| Indent47519-4 | Procedures | O | ||
| Indent29299-5 | Reason for visit | R | ||
| Indent46239-0 | Reason for visit and Chief complaint | R | ||
| Indent30954-2 | Results (Diagnostic findings) | R | ||
| Indent10187-3 | Review of systems | R | ||
| Indent29762-2 | Social history | R | ||
| Indent8716-3 | Vital signs | R |
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
This panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections | |||
| Indent77599-9 | Additional documentation | R | ||
| Indent77598-1 | Externally defined clinical data elements Document | R | ||
| Indent47420-5 | Functional status assessment note | R | ||
| Indent77597-3 | Orders placed Document | R | ||
| Indent18776-5 | Plan of care note | R | ||
| Indent29762-2 | Social history Narrative | R | ||
| Indent77596-5 | Transportation summary Document | R | ||
| Indent42348-3 | Advance directives | O | ||
| Indent48765-2 | Allergies | R | ||
| Indent51847-2 | Evaluation + Plan note | R | ||
| Indent51848-0 | Evaluation note | R | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | R | ||
| Indent10154-3 | Chief complaint Narrative - Reported | R | ||
| Indent46240-8 | History of Hospitalizations+Outpatient visits Narrative | R | ||
| Indent10157-6 | History of family member diseases Narrative | R | ||
| Indent10210-3 | Physical findings of General status Narrative | R | ||
| Indent61146-7 | Goals Narrative | R | ||
| Indent75310-3 | Health concerns Document | R | ||
| Indent11383-7 | Patient problem outcome Narrative | R | ||
| Indent11348-0 | History of Past illness Narrative | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent11369-6 | History of Immunization Narrative | R | ||
| Indent69730-0 | Instructions | R | ||
| Indent62387-6 | Interventions Narrative | R | ||
| Indent46264-8 | History of medical device use | R | ||
| Indent10160-0 | History of Medication use Narrative | R | ||
| Indent10190-7 | Mental status Narrative | R | ||
| Indent61144-2 | Diet and nutrition Narrative | R | ||
| Indent61149-1 | Objective Narrative | R | ||
| Indent48768-6 | Payment sources Document | R | ||
| Indent29545-1 | Physical findings Narrative | R | ||
| Indent11450-4 | Problem list - Reported | R | ||
| Indent47519-4 | History of Procedures Document | R | ||
| Indent42349-1 | Reason for referral (narrative) | R | ||
| Indent29299-5 | Reason for visit Narrative | R | ||
| Indent30954-2 | Relevant diagnostic tests/laboratory data Narrative | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R | ||
| Indent61150-9 | Subjective Narrative | R | ||
| Indent8716-3 | Vital signs | R |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.64
- Last Updated
- Version 2.64
- Order vs. Observation
- Both
- HL7® Attachment Structure
- Implementation guide exists
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38752-8 | Admission history and physical note| |
| LG50065-8 | Gynecology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Historial de admisión y nota física: |
| it-IT | Italian (Italy) | Ricovero, anamnesi e visita medica: Synonyms: Documentazione dell''ontologia Erogazione prescrizione di ricovero: |
| zh-CN | Chinese (China) | 入院史与体格检查记录: Synonyms: 临床文档型; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=89215-8
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