10154-3 Chief complaint

Term Description

Chief complaint records the patient's primary complaint (the patient's own description).

Fully-Specified Name

Component

Chief complaint

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Long Common Name

Chief complaint Narrative - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

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

10164-2 History of present illness

Term Description

History of present illness describes the history related to the reason for a given procedure. It contains the historical details leading up to and pertaining to the patient's current complaint or reason for seeking medical care. Because history of present illness can include past surgical history and other procedures, the Procedure History section may be included under the History of Present Illness section or it may stand alone as its own section.

Fully-Specified Name

Component

Present illness

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Present illness Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

11348-0 History of past illness

Term Description

History of past illness describes the history related to their current complaints, problems, or diagnoses.

Fully-Specified Name

Component

Past illness note

Property

Hx

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

History of Past illness note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• H+P
• H+P.HX
• History
• Last
• notes
• P prime
• Point in time
• Random
• Visit note

56838-6 History of infection

Reference Information

Fully-Specified Name

Component

Infectious disease

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Long Common Name

History of Infectious disease Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.29

Last Updated

Version 2.63 (MIN)

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

10162-6 Pregnancy history

Fully-Specified Name

Component

History of pregnancies

Property

Hx

Time

Pt

System

Reproductive system

Scale

Nar

Method

Long Common Name

History of pregnancies Narrative

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Change Reason

Previous Releases: Changed Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• Gestation
• Gestations
• Gravida
• H/O
• H+P
• H+P.HX
• History
• Hx
• Narrative
• P prime
• Point in time
• Pregnancies Hx
• Pregnancy
• Random
• Report

29762-2 Social history

Term Description

The Social history section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.

Fully-Specified Name

Component

Social history note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Long Common Name

Social history note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

10157-6 Coded family medical history

Term Description

History of family member diseases is a report of health information, including medical, genetic, environmental, and lifestyle factors, pertaining to the patient and his or her genetic relatives (living or deceased). The family history information is used to determine possible or relevant health risk factors that may have a potential impact on the patient's healthcare risk profile.

Fully-Specified Name

Component

History of family member diseases note

Property

Hx

Time

Pt

System

^Family member

Scale

Doc

Method

Long Common Name

History of family member diseases note

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.81 (NAM)

Change Reason

Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements; Previous Releases: Changed Property from "Find" to "Hx", removed Method of "Reported" and corrected System from Family to ^Family member to align with existing family history terms and to represent family member as a Super System per 8/2015 Clinical LOINC Committee decision;

Common Test Rank Get Info

9825

Member of these Panels

Language Variants Get Info

Related Names

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

10187-3 Review of systems

Term Description

The Review of systems section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.

Fully-Specified Name

Component

Review of systems

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Long Common Name

Review of systems Narrative - Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63 (MIN)

Member of these Panels

Language Variants Get Info

Related Names

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

29545-1 Physical exam

Fully-Specified Name

Component

Physical findings note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Long Common Name

Physical findings note

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.81 (NAM)

Change Reason

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

Member of these Panels

Language Variants Get Info

Related Names

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

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.

Fully-Specified Name

Component

Vital signs note

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Observed

Long Common Name

Vital signs note

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 1.0h(3)

Last Updated

Version 2.81 (NAM)

Change Reason

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

Common Test Rank Get Info

576

Member of these Panels

Language Variants Get Info

Related Names

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