48769-4  Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:  

PANEL HIERARCHY  (view this panel in the LForms viewer)

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:    
       34133-9   Summary of episode noteSummary of episode noteSummary of episode note: Find: Pt: {Setting}: Doc: {Role} R    
       48764-5   Summary purpose CCD DocumentSummary purpose CCD DocumentSummary purpose: Find: Pt: ^CCD: Doc: O    
       48768-6   Payment sources DocumentPayment sources DocumentPayment sources: Find: Pt: ^Patient: Doc: O    
       42348-3   Advance directivesAdvance directivesAdvance directives: Find: Pt: {Setting}: Doc: {Role} O 0..*   
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} O    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported O    
       11323-3   General health - ReportedGeneral health - ReportedGeneral health: Find: Pt: ^Patient: Nom: Reported O    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: O    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: O    
       48765-2   Allergies O    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: O    
       46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role} O 0..*   
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: O    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed O    
       30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar: O    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} O    
       46240-8   History of Hospitalizations+​Outpatient visits NarrativeHistory of Hospitalizations+​Outpatient visits NarrativeHospitalizations+​Outpatient visits: Hx: Pt: ^Patient: Nar: O    
       18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role} O 0..*   
       48767-8   Annotation comment [Interpretation] NarrativeAnnotation comment [Interpretation] NarrativeAnnotation comment: Imp: Pt: {system}: Nar: O    
       33999-4   Diagnosis statusDiagnosis statusStatus: Class: Pt: {Diagnosis}: Nom: R    
       48766-0   Information sourceInformation sourceInformation source: Type: Pt: {system}: Nom: R    
 

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Continuity of Care panel  Pt  ^Patient 
  Long Common Name:  Continuity of Care panel
  Short Name:  Continuity of Care Pnl

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: PANEL.DOC/Clinical
  Panel Type: Panel
  First Released in Version: 2.21
  Last Updated in Version: 2.63
  Order vs. Obs.: Order
  Status: Active

PARTS

Part Type    Part No.  Part Name   
Component   LP72312-9  Continuity of Care panel 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Fragments for synonyms   LP21059-8  Panel 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  连续性医疗护理组套:-:时间点:^患者:-:连续性医疗护理组套:-:时间点:^患者:-:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Continuity of Care, panel:-:Pt:^Paziente:-:Continuity of Care, panel:-:Pt:^Paziente:-:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Continuidade dos cuidados painel:-:Pt:^Paciente:-:Continuidade dos cuidados painel:-:Pt:^Paciente:-:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Непрерывность помощи панель:-:ТчкВрм:^Пациент:-:Непрерывность помощи панель:-:ТчкВрм:^Пациент:-:

RELATED NAMES
  CCD PANEL.DOC Point in time
  Continuity of Care Pnl Panl Random
  Pan Pnl  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:48 PM
  Attachment Units Required: N
  Long Common Name: Continuity of Care panel
  Shortname: Continuity of Care Pnl
  Fully Specified Name: Continuity of Care panel: -: Pt: ^Patient: -:
     
  Component Word Count: 4
  ID: 42487
  # of Panel Elements: 22
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



34133-9   Summary of episode noteSummary of episode noteSummary of episode note: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Summary of episode note  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Summary of episode note
  Short Name:  Summary of episode note

TERM DEFINITION/DESCRIPTION(S)
  This LOINC term is currently used as the Clinical Document code for both the Care Record Summary (CRS) and Continuity of Care Document (CCD).
 
 

PART DEFINITION/DESCRIPTION(S)
  Part: Summary of episode note
  Summarization of Episode Note contains an aggregate of pertinent data about a patient from a health care episode. Examples include a Care Record Summary (CRS) and Continuity of Care Document (CCD). CRS includes the summary of the episode, discharge and transfer. CCD includes the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters. Such documents are commonly used in Transfer of Care scenarios.
 
 

OBSERVATION REQUIRED IN PANEL
Required

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.09
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  HL7 Attachment Structure: IG exists
  Status: Active.
Change Reason: Changed Component from 'Summarization of episode' per Clinical LOINC Committee decision to harmonize existing Document Ontology axes values.; 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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

ASSOCIATED OBSERVATIONS

Definition/Description: This panel contains the recommended sections for the continuity of care document [LOINC: 34133-9] based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81214-9   Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:    
       48765-2   Allergies R    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: R    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported R    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} R    
       30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar: R    
       29762-2   Social history R    
       8716-3   Vital signs R    
       42348-3   Advance directivesAdvance directivesAdvance directives: Find: Pt: {Setting}: Doc: {Role} O    
       46240-8   History of Hospitalizations+​Outpatient visits NarrativeHistory of Hospitalizations+​Outpatient visits NarrativeHospitalizations+​Outpatient visits: Hx: Pt: ^Patient: Nar: O    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: O    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} O    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: O    
       10190-7   Mental status NarrativeMental status NarrativeMental status: Find: Pt: ^Patient: Nar: Observed O    
       46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role} O    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: O    
       48768-6   Payment sources DocumentPayment sources DocumentPayment sources: Find: Pt: ^Patient: Doc: O    
       18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role} O    
 

ASSOCIATED OBSERVATIONS

Definition/Description: This panel contains the recommended sections for the continuity of care document [LOINC: 34133-9] based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  72232-2   Continuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:    
       48765-2   Allergies R    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: R    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported R    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} R    
       30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar: R    
       42348-3   Advance directivesAdvance directivesAdvance directives: Find: Pt: {Setting}: Doc: {Role} O    
       46240-8   History of Hospitalizations+​Outpatient visits NarrativeHistory of Hospitalizations+​Outpatient visits NarrativeHospitalizations+​Outpatient visits: Hx: Pt: ^Patient: Nar: O    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: O    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} O    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: O    
       46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role} O    
       48768-6   Payment sources DocumentPayment sources DocumentPayment sources: Find: Pt: ^Patient: Doc: O    
       18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role} O    
       29762-2   Social history O    
       8716-3   Vital signs O    
 

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  69459-6 Care record summary panel
  74293-2 Oncology plan of care and summary - recommended CDA set
  

MEMBER OF THESE EQUIVALENCE GROUPS
  LG38814-6  Summary of episode note|ANYRole|ANYSetting
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP73427-4  Summary of episode note 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP183649-5  note 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  病程摘要记录:发现:时间点:{环境}:文档型:{角色}病程摘要记录:发现:时间点:{环境}:文档型:{角色}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Nota di sintesi di episodio:Osservazione:Pt:{Setting}:Doc:{Role}Nota di sintesi di episodio:Osservazione:Pt:{Setting}:Doc:{Role}
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  nota con síntesis sobre el episodio:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}nota con síntesis sobre el episodio:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}

RELATED NAMES
  CCD Evaluation and management Point in time
  Continuity of Care Document Evaluation and management note Random
  DOC.ONT Finding Visit note
  Document Findings  
  Encounter notes  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Attachment Units Required: N
  Long Common Name: Summary of episode note
  Shortname: Summary of episode note
  Fully Specified Name: Summary of episode note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 4
  ID: 26456
  # of Panel Elements: 16
  Status (Raw): ACTIVE


48764-5   Summary purpose CCD DocumentSummary purpose CCD DocumentSummary purpose: Find: Pt: ^CCD: Doc:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Summary purpose  Find  Pt  ^CCD  Doc 
  Long Common Name:  Summary purpose CCD Document
  Short Name:  Summary purpose CCD Doc

TERM DEFINITION/DESCRIPTION(S)
  Specific reason for which the summarization report was generated.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.21
  Last Updated in Version: 2.27
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  

PARTS

Part Type    Part No.  Part Name   
Component   LP73429-0  Summary purpose 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP62936-7  CCD 
Scale   LP32888-7  Doc 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  摘要目的:发现:时间点:^照护连续性文档:文档型:摘要目的:发现:时间点:^照护连续性文档:文档型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Sintesi, scopo:Osservazione:Pt:^CCD:Doc:Sintesi, scopo:Osservazione:Pt:^CCD:Doc:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Краткие сведения цель:Находка:ТчкВрм:^CCD:Док:Краткие сведения цель:Находка:ТчкВрм:^CCD:Док:

RELATED NAMES
  Continuity of Care Document Finding Point in time
  DOC.MISC Findings Random
  Document MISC  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Attachment Units Required: N
  Long Common Name: Summary purpose CCD Document
  Shortname: Summary purpose CCD Doc
  Fully Specified Name: Summary purpose: Find: Pt: ^CCD: Doc:
     
  Component Word Count: 2
  ID: 42481
  Status (Raw): ACTIVE


48768-6   Payment sources DocumentPayment sources DocumentPayment sources: Find: Pt: ^Patient: Doc:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Payment sources  Find  Pt  ^Patient  Doc 
  Long Common Name:  Payment sources Document
  Short Name:  Payment sources Doc

TERM DEFINITION/DESCRIPTION(S)
  Contains data on the patient's payers, whether a 'third party' insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient's care.

Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient's pertinent current payment sources should be listed.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.21
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  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
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  

PARTS

Part Type    Part No.  Part Name   
Component   LP73082-7  Payment sources 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP32888-7  Doc 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  款项来源:发现:时间点:^患者:文档型:款项来源:发现:时间点:^患者:文档型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Risorse di pagamento:Osservazione:Pt:^Paziente:Doc:Risorse di pagamento:Osservazione:Pt:^Paziente:Doc:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Оплата источник:Находка:ТчкВрм:^Пациент:Док:Оплата источник:Находка:ТчкВрм:^Пациент:Док:

RELATED NAMES
  DOC.MISC Finding Payers
  Document Findings Point in time
  Financing and insurance MISC Random

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Attachment Units Required: N
  Long Common Name: Payment sources Document
  Shortname: Payment sources Doc
  Fully Specified Name: Payment sources: Find: Pt: ^Patient: Doc:
     
  Component Word Count: 2
  ID: 42485
  Status (Raw): ACTIVE


42348-3   Advance directivesAdvance directivesAdvance directives: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Advance directives  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Advance directives
  Short Name:  Advance directives

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

ANSWER CARDINALITY
0..*

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.16
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  57082-0 Antepartum record panel
  57083-8 Labor and Delivery record panel
  69459-6 Care record summary panel
  71531-8 ESRD hospitalization panel
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74449-0 Patient plan of care - recommended IHE set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  82811-1 Nurse summary note - recommended sections
  92574-3 Labor and delivery summary - recommended IHE set
  92576-8 Maternal discharge summary - recommended IHE set
  

MEMBER OF THESE EQUIVALENCE GROUPS
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP74455-4  Advance directives 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP185671-7  Advance 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  事前指示类:发现:时间点:{环境}:文档型:{角色}事前指示类:发现:时间点:{环境}:文档型:{角色}
  German (AUSTRIA)  (From: Regenstrief-generated full translation based on part translation provided by ELGA, Austria)
 
  Patientenverfügung:Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}Patientenverfügung:Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Dichiarazioni anticipate di trattamento:Osservazione:Pt:{Setting}:Doc:{Role}Dichiarazioni anticipate di trattamento:Osservazione:Pt:{Setting}:Doc:{Role}
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Diretivas avançadas:Achado:Pt:^Paciente:Nar:Diretivas avançadas:Achado:Pt:^Paciente:Nar:

RELATED NAMES
  Advanced Finding Random
  DOC.ONT Findings  
  Document Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Attachment Units Required: N
  Long Common Name: Advance directives
  Shortname: Advance directives
  Fully Specified Name: Advance directives: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 2
  ID: 35353
  Status (Raw): ACTIVE


47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Functional status assessment note  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Functional status assessment note
  Short Name:  Functional status note

TERM DEFINITION/DESCRIPTION(S)
  Functional status assessment describes the patient's status of normal functioning at the time a care record was created. Functional statuses include information regarding the patient relative to ambulatory ability, mental status or competency, activities of daily living (ADLs) (i.e. bathing, dressing, feeding, grooming), home/living situation having an effect on the health status of the patient, ability to care for self, social activity (i.e. issues with social cognition, participation with friends and acquaintances other than family members), occupation activity (i.e. activities partly or directly related to working), housework or volunteering, family and home responsibilities or activities related to home and family, communication ability (i.e. issues with speech, writing or cognition required for communication), and perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.19
  Last Updated in Version: 2.66
  Order vs. Obs.: Observation
  HL7 Attachment Structure: No IG exists
  Status: Active.
Change Reason: Based on Clinical LOINC Committee approval on 2/17/2012, "note" was added to the Component as the Kind of Document.; 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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  57053-1 Nurse Emergency department Note
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  74449-0 Patient plan of care - recommended IHE set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  81898-9 Composite triage and nursing note - recommended IHE set
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  

MEMBER OF THESE EQUIVALENCE GROUPS
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP72616-3  Functional status assessment note 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP183649-5  note 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  功能状态评估记录:发现:时间点:{环境}:文档型:{角色}功能状态评估记录:发现:时间点:{环境}:文档型:{角色}
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Funktionelle Statusbeurteilung:Bef:Pkt:{Einstellung}:Dok:{Provider}Funktionelle Statusbeurteilung:Bef:Pkt:{Einstellung}:Dok:{Provider}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Stato funzionale, nota di valutazione:Osservazione:Pt:{Setting}:Doc:{Role}Stato funzionale, nota di valutazione:Osservazione:Pt:{Setting}:Doc:{Role}

RELATED NAMES
  DOC.ONT Finding Random
  Document Findings Visit note
  Encounter Functional status note  
  Evaluation and management notes  
  Evaluation and management note Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Attachment Units Required: N
  Long Common Name: Functional status assessment note
  Shortname: Functional status note
  Fully Specified Name: Functional status assessment note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 4
  ID: 40938
  Status (Raw): ACTIVE


11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Problem list  Find  Pt  ^Patient  Nom  Reported
  Long Common Name:  Problem list - Reported
  Short Name:  Problem list Reported

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0j-a
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
  57082-0 Antepartum record panel
  69459-6 Care record summary panel
  72225-6 Progress note - recommended C-CDA R1.1 sections
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  74449-0 Patient plan of care - recommended IHE set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  82811-1 Nurse summary note - recommended sections
  

PARTS

Part Type    Part No.  Part Name   
Component   LP73189-0  Problem list 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP6486-7  Reported 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  问题列表:发现:时间点:^患者:名义型:报告法问题列表:发现:时间点:^患者:名义型:报告法
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  probleemlijst:bevinding:moment:^patiënt:nominaal:rapportageprobleemlijst:bevinding:moment:^patiënt:nominaal:rapportage
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Liste de problèmes:Observation:Temps ponctuel:^Patient:Nominal:RapportéListe de problèmes:Observation:Temps ponctuel:^Patient:Nominal:Rapporté
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Problemliste:Bef:Pkt:^Patient:Nom:BerichtetProblemliste:Bef:Pkt:^Patient:Nom:Berichtet
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Lista dei problemi:Osservazione:Pt:^Paziente:Nom:RiportatoLista dei problemi:Osservazione:Pt:^Paziente:Nom:Riportato
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Lista de problemas:Achado:Pt:^Paciente:Nom:RelatadoLista de problemas:Achado:Pt:^Paciente:Nom:Relatado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Проблем список:Находка:ТчкВрм:^Пациент:Ном:СообщенныйПроблем список:Находка:ТчкВрм:^Пациент:Ном:Сообщенный
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  lista de problemas:hallazgo:punto en el tiempo:^paciente:Nominal:informadolista de problemas:hallazgo:punto en el tiempo:^paciente:Nominal:informado

RELATED NAMES
  Finding H+P.HX Point in time
  Findings Nominal Random
  H+P P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Long Common Name: Problem list - Reported
  Shortname: Problem list Reported
  Fully Specified Name: Problem list: Find: Pt: ^Patient: Nom: Reported
     
  Component Word Count: 2
  ID: 1642
  Status (Raw): ACTIVE


11323-3   General health - ReportedGeneral health - ReportedGeneral health: Find: Pt: ^Patient: Nom: Reported  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
General health  Find  Pt  ^Patient  Nom  Reported
  Long Common Name:  General health - Reported
  Short Name:  General health Reported

TERM DEFINITION/DESCRIPTION(S)
  Information about the current health status of the patient.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0j-a
  Last Updated in Version: 2.27
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  74293-2 Oncology plan of care and summary - recommended CDA set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72632-0  General health 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP6486-7  Reported 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  总体健康:发现:时间点:^患者:名义型:报告法总体健康:发现:时间点:^患者:名义型:报告法
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Salute generale:Osservazione:Pt:^Paziente:Nom:RiportatoSalute generale:Osservazione:Pt:^Paziente:Nom:Riportato
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Общее состояние здоровья:Находка:ТчкВрм:^Пациент:Ном:СообщенныйОбщее состояние здоровья:Находка:ТчкВрм:^Пациент:Ном:Сообщенный
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  estado general de salud:hallazgo:punto en el tiempo:^paciente:Nominal:informadoestado general de salud:hallazgo:punto en el tiempo:^paciente:Nominal:informado

RELATED NAMES
  Finding H+P.HX Point in time
  Findings Nominal Random
  H+P P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Long Common Name: General health - Reported
  Shortname: General health Reported
  Fully Specified Name: General health: Find: Pt: ^Patient: Nom: Reported
     
  Component Word Count: 2
  ID: 1503
  Status (Raw): ACTIVE


10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
History of family member diseases  Hx  Pt  ^Family member  Nar 
  Long Common Name:  History of family member diseases Narrative
  Short Name:  Family member diseases Hx

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0i
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  35089-2 History and physical panel
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
  57083-8 Labor and Delivery record panel
  59843-3 Procedure note - recommended C-CDA R1.1 sections
  69459-6 Care record summary panel
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  74449-0 Patient plan of care - recommended IHE set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  81898-9 Composite triage and nursing note - recommended IHE set
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  92575-0 Labor and delivery admission history and physical - recommended IHE set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72708-8  History of family member diseases 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6981-7  Family member 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 
Fragments for synonyms   LP100603-2  History of 
Fragments for synonyms   LP91302-7  History 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  家族成员疾病史:历史记录:时间点:^家庭成员:叙述型:家族成员疾病史:历史记录:时间点:^家庭成员:叙述型:
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  geschiedenis van ziekte binnen de familie:historie:moment:^familielid:tekstueel:geschiedenis van ziekte binnen de familie:historie:moment:^familielid:tekstueel:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Anamnèse. Maladies dans la famille:Hx:Temps ponctuel:^membre de famille:Narratif:Anamnèse. Maladies dans la famille:Hx:Temps ponctuel:^membre de famille:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Storia di malattie di membri familiari:Hx:Pt:^membro della famiglia:Nar:Storia di malattie di membri familiari:Hx:Pt:^membro della famiglia:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  История член семьи заболевания:Hx:ТчкВрм:^семьи член:Опис:История член семьи заболевания:Hx:ТчкВрм:^семьи член:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de enfermedades en miembros familiares:hallazgo:punto en el tiempo:familia:Narrativo:informadoantecedentes de enfermedades en miembros familiares:hallazgo:punto en el tiempo:familia:Narrativo:informado

RELATED NAMES
  Fam Mem History Random
  Family member diseases Hx Hx Report
  H/O Narrative  
  H+P P prime  
  H+P.HX Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Long Common Name: History of family member diseases Narrative
  Shortname: Family member diseases Hx
  Fully Specified Name: History of family member diseases: Hx: Pt: ^Family member: Nar:
     
  Component Word Count: 5
  ID: 203
  Status (Raw): ACTIVE


29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Social history  Find  Pt  ^Patient  Nar 
  Long Common Name:  Social history Narrative
  Short Name:  Social Hx

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 2.03
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
  57083-8 Labor and Delivery record panel
  59843-3 Procedure note - recommended C-CDA R1.1 sections
  69459-6 Care record summary panel
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74449-0 Patient plan of care - recommended IHE set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  81898-9 Composite triage and nursing note - recommended IHE set
  92574-3 Labor and delivery summary - recommended IHE set
  92575-0 Labor and delivery admission history and physical - recommended IHE set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP73368-0  Social history 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP91302-7  History 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  社会史:发现:时间点:^患者:叙述型:社会史:发现:时间点:^患者:叙述型:
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  sociale geschiedenis:bevinding:moment:^patiënt:tekstueel:sociale geschiedenis:bevinding:moment:^patiënt:tekstueel:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Histoire sociale:Observation:Temps ponctuel:^Patient:Narratif:Histoire sociale:Observation:Temps ponctuel:^Patient:Narratif:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Sozialanamnese:Bef:Pkt:^Patient:Nar:Sozialanamnese:Bef:Pkt:^Patient:Nar:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Storia sociale:Osservazione:Pt:^Paziente:Nar:Storia sociale:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Histórico social:Achado:Pt:^Paciente:Nar:Histórico social:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Социальная история:Находка:ТчкВрм:^Пациент:Опис:Социальная история:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes sociales:hallazgo:punto en el tiempo:^paciente:Narrativo:antecedentes sociales:hallazgo:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Finding Hx Random
  Findings Narrative Report
  H+P P prime Social Hx
  H+P.HX Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Attachment Units Required: N
  Long Common Name: Social history Narrative
  Shortname: Social Hx
  Fully Specified Name: Social history: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 21551
  Status (Raw): ACTIVE


48765-2   Allergies and adverse reactions DocumentAllergies and adverse reactions DocumentAllergies &or adverse reactions: Find: Pt: ^Patient: Doc:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Allergies &or adverse reactions  Find  Pt  ^Patient  Doc 
  Override Display Name for Form:  Allergies
  Long Common Name:  Allergies and adverse reactions Document
  Short Name:  Allergies &or adverse reactions Doc

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.21
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  57082-0 Antepartum record panel
  57083-8 Labor and Delivery record panel
  59843-3 Procedure note - recommended C-CDA R1.1 sections
  72225-6 Progress note - recommended C-CDA R1.1 sections
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  74449-0 Patient plan of care - recommended IHE set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
  81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  81898-9 Composite triage and nursing note - recommended IHE set
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
  82811-1 Nurse summary note - recommended sections
  84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
  92574-3 Labor and delivery summary - recommended IHE set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP135396-2  Allergies &or adverse reactions   [Allergies and adverse reactions] 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP32888-7  Doc 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  变态反应和或不良反应:发现:时间点:^患者:文档型:变态反应和或不良反应:发现:时间点:^患者:文档型:
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  allergieën en/​of allergische reacties:bevinding:moment:^patiënt:document:allergieën en/​of allergische reacties:bevinding:moment:^patiënt:document:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Allergien, Nebenwirkungen, Warnhinweise:Bef:Pkt:^Patient:Dok:Allergien, Nebenwirkungen, Warnhinweise:Bef:Pkt:^Patient:Dok:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Allergie &o reazioni avverse:Osservazione:Pt:^Paziente:Doc:Allergie &o reazioni avverse:Osservazione:Pt:^Paziente:Doc:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Аллергии &или неблагоприятные реакции:Находка:ТчкВрм:^Пациент:Док:Аллергии &или неблагоприятные реакции:Находка:ТчкВрм:^Пациент:Док:

RELATED NAMES
  DOC.MISC Findings Random
  Document MISC  
  Finding Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:49 PM
  Attachment Units Required: N
  Long Common Name: Allergies and adverse reactions Document
  Shortname: Allergies &or adverse reactions Doc
  Fully Specified Name: Allergies &or adverse reactions: Find: Pt: ^Patient: Doc:
     
  Component Word Count: 4
  ID: 42482
  Status (Raw): ACTIVE


10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Medication use  Hx  Pt  ^Patient  Nar 
  Long Common Name:  History of Medication use Narrative
  Short Name:  Hx of Medication use

TERM DEFINITION/DESCRIPTION(S)
  History of medication use defines a patient's current medications and history of pertinent medications. This term may also include a patient's prescription and dispense history.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0i
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  57083-8 Labor and Delivery record panel
  59843-3 Procedure note - recommended C-CDA R1.1 sections
  69459-6 Care record summary panel
  72225-6 Progress note - recommended C-CDA R1.1 sections
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
  81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  81898-9 Composite triage and nursing note - recommended IHE set
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
  92574-3 Labor and delivery summary - recommended IHE set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72717-9  Medication use 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 
Fragments for synonyms   LP100609-9  Medication 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  用药史:历史记录:时间点:^患者:叙述型:用药史:历史记录:时间点:^患者:叙述型:
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  medicijngebruik:historie:moment:^patiënt:tekstueel:medicijngebruik:historie:moment:^patiënt:tekstueel:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Anamnèse. Utilsation médications:Hx:Temps ponctuel:^Patient:Narratif:Anamnèse. Utilsation médications:Hx:Temps ponctuel:^Patient:Narratif:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Medikationsanamnese:Bef:Pkt:^Patient:Nar:BerichtetMedikationsanamnese:Bef:Pkt:^Patient:Nar:Berichtet
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Uso di farmaci:Hx:Pt:^Paziente:Nar:Uso di farmaci:Hx:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  История лекарственный препарат употребления:Hx:ТчкВрм:^Пациент:Опис:История лекарственный препарат употребления:Hx:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de consumo de medicaciones:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de consumo de medicaciones:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

RELATED NAMES
  H+P Narrative Random
  H+P.HX P prime Report
  History Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Long Common Name: History of Medication use Narrative
  Shortname: Hx of Medication use
  Fully Specified Name: Medication use: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 207
  Status (Raw): ACTIVE


46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
History of medical device use  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  History of medical device use

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

ANSWER CARDINALITY
0..*

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: ATTACH.CLINRPT/Attachment
  First Released in Version: 2.19
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: 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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

EXAMPLE ANSWERS
  C-Pap, Brace, Glucose monitor, Pacemaker, Pin, Etc.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  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
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  82811-1 Nurse summary note - recommended sections
  

PARTS

Part Type    Part No.  Part Name   
Component   LP74100-6  History of medical device use 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP100603-2  History of 
Fragments for synonyms   LP91302-7  History 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  医疗装置使用史:发现:时间点:{环境}:文档型:{角色}医疗装置使用史:发现:时间点:{环境}:文档型:{角色}
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Anamnese Inanspruchnahme medizinischer Geräte:Bef:Pkt:{Einstellung}:Dok:{Provider}Anamnese Inanspruchnahme medizinischer Geräte:Bef:Pkt:{Einstellung}:Dok:{Provider}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Storia di uso di dispositivi medici:Osservazione:Pt:{Setting}:Doc:{Role}Storia di uso di dispositivi medici:Osservazione:Pt:{Setting}:Doc:{Role}
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Histórico da utilização dos dispositivos médicos :Achado:Pt:{Fixação}:Doc:{Fornecedor}Histórico da utilização dos dispositivos médicos :Achado:Pt:{Fixação}:Doc:{Fornecedor}

RELATED NAMES
  ATTACH Findings Point in time
  ATTACH.CLINRPT H/O Random
  Document Hx  
  Finding Medical device use Hx  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Attachment Units Required: N
  Long Common Name: History of medical device use
  Fully Specified Name: History of medical device use: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 5
  ID: 39686
  Status (Raw): ACTIVE


11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Immunization  Hx  Pt  ^Patient  Nar 
  Long Common Name:  History of Immunization Narrative
  Short Name:  Hx of Immunization

TERM DEFINITION/DESCRIPTION(S)
  History of immunizations defines a patient's immunization status for the context and use case of the document type. Often included is current immunization status and possibly the entire immunization history.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0j-a
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Changed Component from "History of immunizations" to "Immunization", Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  69459-6 Care record summary panel
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 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
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  81898-9 Composite triage and nursing note - recommended IHE set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72714-6  Immunization 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  疫苗接种史:历史记录:时间点:^患者:叙述型:疫苗接种史:历史记录:时间点:^患者:叙述型:
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  inenting:historie:moment:^patiënt:tekstueel:inenting:historie:moment:^patiënt:tekstueel:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Anamnèse. Immunisations:Hx:Temps ponctuel:^Patient:Narratif:Anamnèse. Immunisations:Hx:Temps ponctuel:^Patient:Narratif:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Impfanamnese:Bef:Pkt:^Patient:Nar:BerichtetImpfanamnese:Bef:Pkt:^Patient:Nar:Berichtet
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Immunizzazioni:Hx:Pt:^Paziente:Nar:Immunizzazioni:Hx:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  История иммунизаций:Hx:ТчкВрм:^Пациент:Опис:История иммунизаций:Hx:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedente de inmunización:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedente de inmunización:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

RELATED NAMES
  H+P Immunization status Point in time
  H+P.HX Narrative Random
  History P prime Report

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Long Common Name: History of Immunization Narrative
  Shortname: Hx of Immunization
  Fully Specified Name: Immunization: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 1
  ID: 1553
  Status (Raw): ACTIVE


8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Vital signs  Find  Pt  ^Patient  Nar  Observed
  Long Common Name:  Vital signs
  Short Name:  Vital signs

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 1.0h(3)
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  57053-1 Nurse Emergency department Note
  57083-8 Labor and Delivery record panel
  69459-6 Care record summary panel
  72225-6 Progress note - recommended C-CDA R1.1 sections
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  81898-9 Composite triage and nursing note - recommended IHE set
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
  82811-1 Nurse summary note - recommended sections
  84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
  92575-0 Labor and delivery admission history and physical - recommended IHE set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP139953-6  Vital signs 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Method   LP6425-5  Observed 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  生命体征:发现:时间点:^患者:叙述型:观察法生命体征:发现:时间点:^患者:叙述型:观察法
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Signes vitaux:Observation:Temps ponctuel:^Patient:Narratif:ObservéSignes vitaux:Observation:Temps ponctuel:^Patient:Narratif:Observé
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Physikalische Befunde:Bef:Pkt:Vitalzeichen:Nar:BeobachtetPhysikalische Befunde:Bef:Pkt:Vitalzeichen:Nar:Beobachtet
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Segni vitali:Osservazione:Pt:^Paziente:Nar:OsservatoSegni vitali:Osservazione:Pt:^Paziente:Nar:Osservato
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Achados físicos:Achado:Pt:Sinais vitais:Nar:ObservadoAchados físicos:Achado:Pt:Sinais vitais:Nar:Observado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Жизненно важные функции:Находка:ТчкВрм:^Пациент:Опис:НаблюдённыйЖизненно важные функции:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  hallazgos físicos:hallazgo:punto en el tiempo:signos vitales:Narrativo:observadohallazgos físicos:hallazgo:punto en el tiempo:signos vitales:Narrativo:observado

RELATED NAMES
  Finding H+P.PX Point in time
  Findings Narrative Random
  H+P P prime Report

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Long Common Name: Vital signs
  Shortname: Vital signs
  Fully Specified Name: Vital signs: Find: Pt: ^Patient: Nar: Observed
     
  Component Word Count: 2
  ID: 66230
  Status (Raw): ACTIVE


30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Relevant diagnostic tests &or laboratory data  Find  Pt  ^Patient  Nar 
  Long Common Name:  Relevant diagnostic tests/laboratory data Narrative
  Short Name:  Relevant Dx tests/lab data

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: VACCIN/Clinical
  First Released in Version: 2.04
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55140-8 Vaccine Adverse Event Reporting System (VAERS) panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  57083-8 Labor and Delivery record panel
  69459-6 Care record summary panel
  72225-6 Progress note - recommended C-CDA R1.1 sections
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  82811-1 Nurse summary note - recommended sections
  92574-3 Labor and delivery summary - recommended IHE set
  92576-8 Maternal discharge summary - recommended IHE set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP73277-3  Relevant diagnostic tests &or laboratory data   [Relevant diagnostic tests/laboratory data] 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  相关诊断试验和或实验室数据:发现:时间点:^患者:叙述型:相关诊断试验和或实验室数据:发现:时间点:^患者:叙述型:
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  relevante diagnostische tests en/​of laboratoriumgegevens:bevinding:moment:^patiënt:tekstueel:relevante diagnostische tests en/​of laboratoriumgegevens:bevinding:moment:^patiënt:tekstueel:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Test de diagnostic utiles et données de laboratoire:Observation:Temps ponctuel:^Patient:Narratif:Test de diagnostic utiles et données de laboratoire:Observation:Temps ponctuel:^Patient:Narratif:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Relevante diagnostische Tests &oder Labordaten:Bef:Pkt:^Patient:Nar:Relevante diagnostische Tests &oder Labordaten:Bef:Pkt:^Patient:Nar:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Test diagnostici rilevanti &o dati di laboratorio:Osservazione:Pt:^Paziente:Nar:Test diagnostici rilevanti &o dati di laboratorio:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Testes diagnósticos relevantes e/​ou dados laboratóriais:Achado:Pt:^Paciente:Nar:Testes diagnósticos relevantes e/​ou dados laboratóriais:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Значимый диагностический тест &или лабораторные данные:Находка:ТчкВрм:^Пациент:Опис:Значимый диагностический тест &или лабораторные данные:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  pruebas diagnósticas relevantes y/​o información de laboratorio:hallazgo:punto en el tiempo:^paciente:Narrativo:pruebas diagnósticas relevantes y/​o información de laboratorio:hallazgo:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Finding Point in time Report
  Findings Random VACCINE
  Narrative Relevant Dx tests/lab data  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Attachment Units Required: N
  Long Common Name: Relevant diagnostic tests/laboratory data Narrative
  Shortname: Relevant Dx tests/lab data
  Fully Specified Name: Relevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 6
  ID: 22892
  Status (Raw): ACTIVE


47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
History of procedures  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  History of Procedures Document
  Short Name:  Procedures Hx Doc

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 2.19
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  57053-1 Nurse Emergency department Note
  59843-3 Procedure note - recommended C-CDA R1.1 sections
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  74449-0 Patient plan of care - recommended IHE set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  81898-9 Composite triage and nursing note - recommended IHE set
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  82811-1 Nurse summary note - recommended sections
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72725-2  History of Procedures 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP100603-2  History of 
Fragments for synonyms   LP91302-7  History 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作史:发现:时间点:{环境}:文档型:{角色}操作史:发现:时间点:{环境}:文档型:{角色}
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Behandlungsanamnese:Bef:Pkt:{Einstellung}:Dok:{Provider}Behandlungsanamnese:Bef:Pkt:{Einstellung}:Dok:{Provider}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Storia di Procedure:Osservazione:Pt:{Setting}:Doc:{Role}Storia di Procedure:Osservazione:Pt:{Setting}:Doc:{Role}
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Histórico de procedimentos:Achado:Pt:{Fixação}:Doc:{Fornecedor}Histórico de procedimentos:Achado:Pt:{Fixação}:Doc:{Fornecedor}

RELATED NAMES
  Document H+P Point in time
  Finding H+P.HX Procedures Hx
  Findings Hx Random
  H/O P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Attachment Units Required: N
  Long Common Name: History of Procedures Document
  Shortname: Procedures Hx Doc
  Fully Specified Name: History of procedures: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 3
  ID: 41048
  Status (Raw): ACTIVE


46240-8   History of Hospitalizations+​Outpatient visits NarrativeHistory of Hospitalizations+​Outpatient visits NarrativeHospitalizations+​Outpatient visits: Hx: Pt: ^Patient: Nar:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Hospitalizations+Outpatient visits  Hx  Pt  ^Patient  Nar 
  Long Common Name:  History of Hospitalizations+Outpatient visits Narrative
  Short Name:  Hx of Hospitalizations+OP visits

TERM DEFINITION/DESCRIPTION(S)
  History of hospitalizations and History of outpatient visits (i.e. Encounters) lists and describes any healthcare encounters pertinent to the patient's current health status or historical health history. An encounter is an interaction, regardless of the setting, between a patient and a practitioner who is vested with primary responsibility for diagnosing, evaluating, or treating the patient's condition. It may include visits, appointments, as well as non face-to-face interactions. It is also a contact between a patient and a practitioner who has primary responsibility for assessing and treating the patient at a given contact, exercising independent judgment.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 2.19
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  51896-9 Healthcare Associated Infection report - recommended CDA R2 sections
  69459-6 Care record summary panel
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72713-8  Hospitalizations+Outpatient visits 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP100611-5  Outpatient 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  住院治疗史+​门诊就诊史:历史记录:时间点:^患者:叙述型:住院治疗史+​门诊就诊史:历史记录:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Ospedalizzazioni+​Visite ambulatoriali:Hx:Pt:^Paziente:Nar:Ospedalizzazioni+​Visite ambulatoriali:Hx:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Histórico de hospitalizações+​ Histórico de visitas ambulatoriais:Achado:Pt:^Paciente:Nar:RelatadoHistórico de hospitalizações+​ Histórico de visitas ambulatoriais:Achado:Pt:^Paciente:Nar:Relatado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  История госпитализаций+​История амбулаторных визитов:Hx:ТчкВрм:^Пациент:Опис:История госпитализаций+​История амбулаторных визитов:Hx:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  H+P Narrative Point in time
  H+P.HX OP Random
  History Outpt visits Report
  Hospitalizations+OP visits P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Attachment Units Required: N
  Long Common Name: History of Hospitalizations+Outpatient visits Narrative
  Shortname: Hx of Hospitalizations+OP visits
  Fully Specified Name: Hospitalizations+Outpatient visits: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 39660
  Status (Raw): ACTIVE


18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Plan of care note  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Plan of care note
  Short Name:  Plan of care note

TERM DEFINITION/DESCRIPTION(S)
  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.
 
 

ANSWER CARDINALITY
0..*

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 1.0l
  Last Updated in Version: 2.66
  HL7 Attachment Structure: IG exists
  Status: Active.
Change Reason: 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}.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

ASSOCIATED OBSERVATIONS

Definition/Description: This panel contains the recommended sections for a care plan note based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81215-6   Care plan - recommended C-CDA R2.0 and R2.1 sectionsCare plan - recommended C-CDA R2.0 and R2.1 sectionsCare plan - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:    
       61146-7   Goals NarrativeGoals NarrativeGoals: Find: Pt: ^Patient: Nar: R    
       75310-3   Health concerns DocumentHealth concerns DocumentHealth concerns: Find: Pt: ^Patient: Doc: R    
       11383-7   Patient problem outcome NarrativePatient problem outcome NarrativePatient problem outcome: Find: Pt: ^Patient: Nar: O    
       62387-6   Interventions NarrativeInterventions NarrativeInterventions: Find: Pt: ^Patient: Nar: O    
 

ASSOCIATED OBSERVATIONS

Definition/Description: The recommended set of terms for use within a Plan of care note [LOINC: 18776-5] based on the IHE Patient Plan of Care (PPOC) profile.

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:    
       48765-2   Allergies and other adverse reactions R    
       29545-1   Physical examination C    
       51848-0   Assessment R    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported C    
       11450-4   Active problems R    
       47420-5   Functional status C    
       10157-6   Family history O    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: O    
       42348-3   Advance directivesAdvance directivesAdvance directives: Find: Pt: {Setting}: Doc: {Role} R    
       18610-6   Medications administered C    
       8975-5   Fluids administered C   cm3 
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: C    
       47519-4   Procedures and interventions C    
       46209-3   Provider ordersProvider ordersProvider orders: Find: -: ^Patient: Doc: R    
 

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  57082-0 Antepartum record panel
  59843-3 Procedure note - recommended C-CDA R1.1 sections
  69459-6 Care record summary panel
  72225-6 Progress note - recommended C-CDA R1.1 sections
  72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  72229-8 Discharge summary - recommended C-CDA R1.1 sections
  72231-4 Consultation note - recommended C-CDA R1.1 sections
  72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
  74293-2 Oncology plan of care and summary - recommended CDA set
  81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
  81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
  81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
  81218-0 Discharge summary - recommended C-CDA R2.1 sections
  81219-8 Discharge summary - recommended C-CDA R2.0 sections
  81221-4 Transfer summary note - recommended C-CDA R2.0 sections
  81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
  81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
  81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
  81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
  81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
  81614-0 Transfer summary note - recommended C-CDA R2.1 sections
  81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
  82811-1 Nurse summary note - recommended sections
  

MEMBER OF THESE EQUIVALENCE GROUPS
  LG38745-2  Plan of care note|ANYRole|ANYSetting
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP157909-5  Plan of care note 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP183649-5  note 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  医疗服务计划记录:发现:时间点:{环境}:文档型:{角色}医疗服务计划记录:发现:时间点:{环境}:文档型:{角色}
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Behandlungsplan:Bef:Pkt:Behandlungsplan:Nar:Behandlungsplan:Bef:Pkt:Behandlungsplan:Nar:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:{Role}Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:{Role}
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  plan de tratamiento:hallazgo:punto en el tiempo:plan de tratamiento:Narrativo:plan de tratamiento:hallazgo:punto en el tiempo:plan de tratamiento:Narrativo:

RELATED NAMES
  Care plan Evaluation and management note Random
  DOC.ONT Finding Treatment plan
  Document Findings Visit note
  Encounter notes  
  Evaluation and management Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Long Common Name: Plan of care note
  Shortname: Plan of care note
  Fully Specified Name: Plan of care note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 4
  ID: 9693
  # of Panel Elements: 15
  Status (Raw): ACTIVE


48767-8   Annotation comment [Interpretation] NarrativeAnnotation comment [Interpretation] NarrativeAnnotation comment: Imp: Pt: {system}: Nar:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Annotation comment  Imp  Pt  {system}  Nar 
  Long Common Name:  Annotation comment [Interpretation] Narrative
  Short Name:  Annotation comment Imp

TERM DEFINITION/DESCRIPTION(S)
  This is an observation code indicating that a particular observation represents a free text annotation comment that can be appended to some other observation such as a lab result.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.21
  Last Updated in Version: 2.50
  Order vs. Obs.: Observation
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  86535-2 Healthcare associated infection report - recommended CDA R3 set
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72080-2  Annotation comment 
Property   LP6819-9  Imp   [Impression/interpretation of study] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP76034-5  {system} 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP20987-1  Comment 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  注释:印象:时间点:{系统}:叙述型:注释:印象:时间点:{系统}:叙述型:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Annotation commentaire:Impression/​interprétation d'étude:Temps ponctuel:{système}:Narratif:Annotation commentaire:Impression/​interprétation d'étude:Temps ponctuel:{système}:Narratif:
  French (CANADA)  (From: Regenstrief-generated full translation based on part translation provided by Canada Health Infoway Inc.)
 
  Annotation commentaire:Impression/​interprétation d'étude:Temps ponctuel:{système}:Narratif:Annotation commentaire:Impression/​interprétation d'étude:Temps ponctuel:{système}:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Annotazioni e commenti:Imp:Pt:{system}:Nar:Annotazioni e commenti:Imp:Pt:{system}:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Аннотация комментарий:Впчт:ТчкВрм:{система}:Опис:Аннотация комментарий:Впчт:ТчкВрм:{система}:Опис:

RELATED NAMES
  cmmt Impression Point in time
  cmnt Impression/interpretation of study Random
  Com Impressions Remarks
  Comm Interp Report
  Comments Interpretation  
  Commt MISC  
  DOC.MISC Narrative  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:50 PM
  Attachment Units Required: N
  Long Common Name: Annotation comment [Interpretation] Narrative
  Shortname: Annotation comment Imp
  Fully Specified Name: Annotation comment: Imp: Pt: {system}: Nar:
     
  Component Word Count: 2
  ID: 42484
  Status (Raw): ACTIVE


33999-4   Diagnosis statusDiagnosis statusStatus: Class: Pt: {Diagnosis}: Nom:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Status  Class  Pt  {Diagnosis}  Nom 
  Long Common Name:  Diagnosis status
  Short Name:  Status {Dx}

TERM DEFINITION/DESCRIPTION(S)
  This term classifies the status of a diagnosis.
 
 

OBSERVATION REQUIRED IN PANEL
Required

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DENTAL/Clinical
  First Released in Version: 2.09
  Last Updated in Version: 2.64
  Status: Active.
Change Reason: Changed answer list from "Normative" to "Example" to fit the current LOINC model.; Updated Long Common Name to better represent the meaning of the term.

EXAMPLE ANSWER LIST    (LL451-6)  
 
Source: 
  SEQ#        Answer        Answer ID    
  1       New       LA9039-4  
  2       Ongoing       LA9040-2  
  3       Resolved       LA9041-0  
  4       Finding       LA9042-8  
  5       Observe       LA9043-6  
  6       Provisional       LA9044-4  
  7       Confirm negative       LA9045-1  
  8       Unable to Confirm       LA9046-9  
  9       Deleted       LA9047-7  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  74293-2 Oncology plan of care and summary - recommended CDA set
  89724-9 Minimum Data Set (MDS) for Public Health Emergency Operations Centers (EOC) [CDC Emergency Operations Centers]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP73412-6  Status 
Property   LP6795-1  Class 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP76024-6  {Diagnosis} 
Scale   LP7750-5  Nom 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  状态:分类:时间点:{诊断}:名义型:状态:分类:时间点:{诊断}:名义型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Stato:Classe:Pt:{Diagnosi}:Nom:Stato:Classe:Pt:{Diagnosi}:Nom:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Condição:Class:Pt:{Diagnóstico}:Nom:Condição:Class:Pt:{Diagnóstico}:Nom:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Статус:Класс:ТчкВрм:{Диагноз}:Ном:Статус:Класс:ТчкВрм:{Диагноз}:Ном:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  estado:clase:punto en el tiempo:{diagnóstico}:Nominal:estado:clase:punto en el tiempo:{diagnóstico}:Nominal:

RELATED NAMES
  {Dx} Random  
  Nominal    
  Point in time    

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:51 PM
  Attachment Units Required: N
  Long Common Name: Diagnosis status
  Shortname: Status {Dx}
  Fully Specified Name: Status: Class: Pt: {Diagnosis}: Nom:
     
  Component Word Count: 1
  ID: 26306
  Status (Raw): ACTIVE


48766-0   Information sourceInformation sourceInformation source: Type: Pt: {system}: Nom:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Information source  Type  Pt  {system}  Nom 
  Long Common Name:  Information source
  Short Name:  Source of info

TERM DEFINITION/DESCRIPTION(S)
  The information or data source may be a person, organization, information system, reference to some other data object, etc.
 
 

OBSERVATION REQUIRED IN PANEL
Required

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.21
  Last Updated in Version: 2.66
  Status: Active

EXAMPLE ANSWER LIST    (LL3678-1)  
 
Externally Defined: Y
Source: Centers for Disease Control and Prevention
Link to external list: https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.3036

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  48769-4 Continuity of Care panel
  55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
  55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
  71531-8 ESRD hospitalization panel
  78000-7 Case notification panel [CDC.PHIN]
  85735-9 Congenital rubella case report panel
  88028-6 Tobacco use panel
  89724-9 Minimum Data Set (MDS) for Public Health Emergency Operations Centers (EOC) [CDC Emergency Operations Centers]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP72797-1  Information source 
Property   LP6886-8  Type 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP76034-5  {system} 
Scale   LP7750-5  Nom 
Fragments for synonyms   LP21212-3  Source 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  信息来源:类型:时间点:{系统}:名义型:信息来源:类型:时间点:{系统}:名义型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Fonte informativa:Tipo:Pt:{system}:Nom:Fonte informativa:Tipo:Pt:{system}:Nom:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Информация источник:Тип:ТчкВрм:{система}:Ном:Информация источник:Тип:ТчкВрм:{система}:Ном:

RELATED NAMES
  DOC.MISC Point in time Srce
  MISC Random Typ
  Nominal Source of info  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 5:19:51 PM
  Attachment Units Required: N
  Long Common Name: Information source
  Shortname: Source of info
  Fully Specified Name: Information source: Type: Pt: {system}: Nom:
     
  Component Word Count: 2
  ID: 42483
  Status (Raw): ACTIVE