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.
Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details.
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
LOINC Names Get Info
- Fully-Specified Name
- Admission history and physical note:
Find: Pt: {Setting}: Doc: Gynecology - Long Common Name
- Gynecology Admission History and Physical Note
- Short Name
- Gynecology Admit H&P Note
Part Model Get Info
- Component
- Admission history and physical note
LP57379-7
- Analyte
- Admission history and physical note
LP57379-7
- Challenge
- NULL
- Adjustment
- NULL
- Count
- NULL
- Property
- Find
LP6813-2
- Time
- Pt
LP6960-1
- Time Core
- Pt
LP6960-1
- Time Modifier
- NULL
- System
- {Setting}
LP32887-9
- System Core
- {Setting}
LP32887-9
- Super System
- NULL
- Scale
- Doc
LP32888-7
- Method
- Gynecology
LP32899-4
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 note | R | ||
| Indent77596-5 | Transportation summary Document | R | ||
| Indent42348-3 | Advance Healthcare 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 note | 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 note | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent11369-6 | History of Immunization note | 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 note | 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 note | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R | ||
| Indent61150-9 | Subjective Narrative | R | ||
| Indent8716-3 | Vital signs note | R |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.64
- Last Updated
- Version 2.64 (ADD)
- 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 |
|---|---|---|
| el-GR | Greek (Greece) | Ιστορικό και φυσική κατάσταση εισαγωγής: Synonyms: {Ρυθμίσεις} Doc DOC.ONTOLOGY Pt Γυναικολογία Εύρεση Ιστορικό και φυσική κατάσταση εισαγωγής Σημείωμα ιστορικού και φυσικής εξέτασης Σημείωση |
| 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
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LOINC Copyright
Copyright © Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://