57057-2  Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}  

PANEL HIERARCHY

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  57057-2   Labor and delivery summary    
       46241-6   Hospital admission diagnosis    
       10154-3   Chief complaint    
       11459-5   Transport mode    
       10160-0   Admission medication history    
       51847-2   Assessment and plan    
       30954-2   Coded results    
       10164-2   History of present illness    
       11348-0   History of past illness    
       56838-6   Coded history of infection    
       42348-3   Coded advanced directives    
       57079-6   Birth plan    
       48765-2   Allergies and other adverse reactions    
       29545-1   Coded physical exam    
       10162-6   Pregnancy history    
       57060-6   Estimated delivery dates    
       29762-2   Coded social history    
       18610-6   Medications administered    
       57072-1   Intravenous fluids administered    
       57073-9   Prenatal events    
       10167-5   List of surgeries    
       57074-7   Labor and delivery process    
       57075-4   Newborn delivery information    
       55103-6   Estimated blood loss    
       57078-8   Coded antenatal testing and surveillance    
 

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Labor and delivery summary note  Find  Pt  {Setting}  Doc  {Role}
  Override Display Name for Form:  Labor and delivery summary
  Long Common Name:  Labor and delivery summary note
  Shortname:  L&D summary note

TERM DEFINITION/DESCRIPTION(S)
  The Labor and Delivery Summary (LDS) profile document represents a summary of the most critical information concerning the labor and delivery care in a birthing facility. The LDS is a medical summary and inherits all header constraints from Medical Summaries. It also uses parts of the History and Physical profile where needed.
 
 

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  Panel Type: Panel
  First Released in Version: 2.29
  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
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:

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

PARTS

Part Type    Part No.  Part Name   
Component   LP96927-6  Labor and delivery summary 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)
 
  临产和分娩摘要记录:发现:时间点:{环境}:文档型:{角色}临产和分娩摘要记录: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)
 
  Geburtsbericht (ärztlich):Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}Geburtsbericht (ärztlich):Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Travaglio e parto, sintesi:Osservazione:Pt:{Setting}:Doc:{Role}Travaglio e parto, sintesi:Osservazione:Pt:{Setting}:Doc:{Role}

RELATED NAMES
  DOC.ONT Finding Random
  Document Findings Visit note
  Encounter L&D summary note  
  Evaluation and management notes  
  Evaluation and management note Point in time  

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:25 AM
  Attachment Units Required: N
  Long Common Name: Labor and delivery summary note
  Shortname: L&D summary note
  Fully Specified Name: Labor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 5
  ID: 51680
  # of Panel Elements: 25
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



46241-6   Hospital admission diagnosis Narrative - ReportedHospital admission diagnosis Narrative - ReportedHospital admission Dx: Imp: Pt: ^Patient: Nar: Reported  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Hospital admission Dx  Imp  Pt  ^Patient  Nar  Reported
  Override Display Name for Form:  Hospital admission diagnosis
  Long Common Name:  Hospital admission diagnosis Narrative - Reported
  Shortname:  Hospital admission Dx Reported

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: 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
  Cholecystitis

MEMBER OF THESE PANELS
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59271-7   Hospital discharge summary panelHospital discharge summary panelHospital discharge summary panel: -: Pt: ^Patient: -:
  62863-6   PhenX domain - Infectious diseases and immunityPhenX domain - Infectious diseases and immunityPhenX domain - Infectious diseases and immunity: -: Pt: ^Patient: -: PhenX
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72744-3  Hospital admission Dx   [Hospital admission diagnosis] 
Property   LP6819-9  Imp   [Impression/interpretation of study] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Method   LP6486-7  Reported 
Fragments for synonyms   LP75922-2  P' 
Fragments for synonyms   LP30831-9  Dx 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  医院入院诊断:印象:时间点:^患者:叙述型:报告法医院入院诊断:印象:时间点:^患者:叙述型:报告法
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Documents admission hôpital:Impression/​interprétation d'étude:Temps ponctuel:^Patient:Narratif:RapportéDocuments admission hôpital:Impression/​interprétation d'étude:Temps ponctuel:^Patient:Narratif:Rapporté
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Ricovero ospedaliero, Dx:Imp:Pt:^Paziente:Nar:RiportatoRicovero ospedaliero, Dx:Imp:Pt:^Paziente:Nar:Riportato
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Admissão hospitalar Dx:Imp:Pt:^Paciente:Nar:RelatadoAdmissão hospitalar Dx:Imp:Pt:^Paciente:Nar:Relatado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Госпитализация Dx:Впчт:ТчкВрм:^Пациент:Опис:СообщенныйГоспитализация Dx:Впчт:ТчкВрм:^Пациент:Опис:Сообщенный

RELATED NAMES
  Diagnosis Impression/interpretation of study P prime
  H+P Impressions Point in time
  H+P.HX Interp Random
  Hosp Interpretation Report
  Impression Narrative  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:26 AM
  Attachment Units Required: N
  Long Common Name: Hospital admission diagnosis Narrative - Reported
  Shortname: Hospital admission Dx Reported
  Fully Specified Name: Hospital admission Dx: Imp: Pt: ^Patient: Nar: Reported
     
  Component Word Count: 3
  ID: 39661
  Status (Raw): ACTIVE


10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Chief complaint  Find  Pt  ^Patient  Nar  Reported
  Override Display Name for Form:  Chief complaint
  Long Common Name:  Chief complaint Narrative - Reported
  Shortname:  Chief complaint Reported

TERM DEFINITION/DESCRIPTION(S)
  Chief complaint records the patient's primary complaint (the patient's own description).
 
 

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0i
  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
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  55169-7   Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0: -: Pt: ^Patient: -:
  57056-4   Labor and delivery admission history and physical noteLabor and delivery admission history and physical noteLabor and delivery admission history and physical note: Find: Pt: {Setting}: Doc: {Role}
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74028-2   Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDSVirtual Medical Record for Clinical Decision Support panel HL7.VMR-CDSVirtual medical record for clinical decision support panel: -: Pt: ^Patient: -: HL7.VMR-CDS
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:
  84428-2   National EMS Information System - version 3 setNational EMS Information System - version 3 setNational EMS Information System - version 3 set: -: Pt: {Setting}: -:
  84429-0   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 set: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72244-4  Chief complaint 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
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)
 
  主诉:发现:时间点:^患者:叙述型:报告法主诉:发现:时间点:^患者:叙述型:报告法
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Plainte principale:Observation:Temps ponctuel:^Patient:Narratif:RapportéPlainte principale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Disturbo principale:Osservazione:Pt:^Paziente:Nar:RiportatoDisturbo principale:Osservazione:Pt:^Paziente:Nar:Riportato
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Основная жалоба:Находка:ТчкВрм:^Пациент:Опис:СообщенныйОсновная жалоба:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  motivo de consulta principal:hallazgo:punto en el tiempo:^paciente:Narrativo:informadomotivo de consulta principal:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:26 AM
  Long Common Name: Chief complaint Narrative - Reported
  Shortname: Chief complaint Reported
  Fully Specified Name: Chief complaint: Find: Pt: ^Patient: Nar: Reported
     
  Component Word Count: 2
  ID: 131
  Status (Raw): ACTIVE


11459-5   Transport mode EMS systemTransport mode EMS systemTransport mode: Type: Pt: EMS system: Nom:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Transport mode  Type  Pt  EMS system  Nom 
  Override Display Name for Form:  Transport mode
  Long Common Name:  Transport mode EMS system
  Shortname:  Transport mode EMS Sys

BASIC ATTRIBUTES
  Class/Type: ED/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.

EXAMPLE ANSWER LIST    (LL483-9)  
 
Source: 
  SEQ#        Answer        Code         Answer ID    
  0       Ground ambulance       10       LA9315-8  
  1       Helicopter ambulance       20       LA9316-6  
  2       Fixed-wing air ambulance       30       LA9317-4  
  3       Ambulance, not otherwise specified       40       LA9318-2  
  4       Walk-in following transport via private transportation       50       LA9319-0  
  5       Walk-in following transport via public transportation       60       LA9320-8  
  6       Walk-in following nonambulance, law enforcement transport       70       LA9321-6  
  7       Walk-in, not otherwise specified       80       LA9322-4  
  8       Other mode of transport       88       LA9323-2  
  9       Unknown mode of transport       99       LA9324-0  

MEMBER OF THESE PANELS
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  55169-7   Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:
  88677-0   German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol setGerman Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol setGerman Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73551-1  Transport mode 
Property   LP6886-8  Type 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP7199-5  EMS system 
Scale   LP7750-5  Nom 
Fragments for synonyms   LP57605-5  EMS 
Fragments for synonyms   LP57608-9  ED 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  运输方式:类型:时间点:急救医疗服务系统:名义型:运输方式:类型:时间点:急救医疗服务系统:名义型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Trasporto, modo:Tipo:Pt:Servizio di pronto intervento sanitario, sistema:Nom:Trasporto, modo:Tipo:Pt:Servizio di pronto intervento sanitario, sistema:Nom:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Modo de transporte:Tipo:Pt:Sistema EMS:Nom:Modo de transporte:Tipo:Pt:Sistema EMS:Nom:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Транспортировка режим:Тип:ТчкВрм:Скорая медицинская помощь система:Ном:Транспортировка режим:Тип:ТчкВрм:Скорая медицинская помощь система:Ном:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  TRANSPORT MODE:tipo:punto en el tiempo:sistema de servicio médico de urgencias:Nominal:TRANSPORT MODE:tipo:punto en el tiempo:sistema de servicio médico de urgencias:Nominal:

RELATED NAMES
  DEEDS EMS Random
  Emergency Department NEMSIS Typ
  EMERGENCY DEPARTMENT (DEEDS) Nominal  
  Emergency Medical Service(s) Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:26 AM
  Long Common Name: Transport mode EMS system
  Shortname: Transport mode EMS Sys
  Fully Specified Name: Transport mode: Type: Pt: EMS system: Nom:
     
  Component Word Count: 2
  ID: 1652
  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 
  Override Display Name for Form:  Admission medication history
  Long Common Name:  History of Medication use Narrative
  Shortname:  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.
 
 

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
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  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}: -:
  74293-2   Oncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA set: -: Pt: {Setting}: -:
  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}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  88677-0   German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol setGerman Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol setGerman Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set: -: Pt: {Setting}: -:

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   LP100609-9  Medication 
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)
 
  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:
  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: 12/13/2018 1:28:27 AM
  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


51847-2   Evaluation +​ Plan noteEvaluation +​ Plan noteEvaluation+​Plan note: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Evaluation+Plan note  Find  Pt  {Setting}  Doc  {Role}
  Override Display Name for Form:  Assessment and plan
  Long Common Name:  Evaluation + Plan note
  Shortname:  Eval+Plan note

TERM DEFINITION/DESCRIPTION(S)
  The Assessment and Plan note (also called impression or diagnoses) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block. The Plan section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education was given or will be provided.
 
 

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.24
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  Status: Active.
Change Reason: Changed 'Assesment' to 'Evaluation' to harmonize existing terms with similar meaning. The term 'Evaluation' will be used in the LOINC Document Ontoloy based on Clinical LOINC Committee decision (Sept 2014).; 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
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:

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

PARTS

Part Type    Part No.  Part Name   
Component   LP74505-6  Evaluation+Plan note   [Evaluation + Plan 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 
Fragments for synonyms   LP21013-5  Evaluation 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  评价+​计划记录:发现:时间点:{环境}:文档型:{角色}评价+​计划记录: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)
 
  Valutazione+​Nota di piano:Osservazione:Pt:{Setting}:Doc:{Role}Valutazione+​Nota di piano:Osservazione:Pt:{Setting}:Doc:{Role}

RELATED NAMES
  Assessment Eval+Plan note History and physical
  Assessment+Plan note Evaluation and management notes
  DOC.ONT Evaluation and management note Point in time
  Document Finding Random
  Encounter Findings Visit note
  Eval H&P  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:27 AM
  Attachment Units Required: N
  Long Common Name: Evaluation + Plan note
  Shortname: Eval+Plan note
  Fully Specified Name: Evaluation+Plan note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 3
  ID: 45852
  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 
  Override Display Name for Form:  Coded results
  Long Common Name:  Relevant diagnostic tests/laboratory data Narrative
  Shortname:  Relevant Dx tests/lab data

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
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  55140-8   Vaccine Adverse Event Reporting System (VAERS) panelVaccine Adverse Event Reporting System (VAERS) panelVaccine Adverse Event Reporting System panel: -: Pt: ^Patient: -:
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  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}: -:
  74293-2   Oncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA set: -: Pt: {Setting}: -:
  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}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

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:
  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: 12/13/2018 1:28:27 AM
  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


10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Present illness  Hx  Pt  ^Patient  Nar 
  Override Display Name for Form:  History of present illness
  Long Common Name:  History of Present illness Narrative
  Shortname:  Hx of Pres illness

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

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
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  55169-7   Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0: -: Pt: ^Patient: -:
  57056-4   Labor and delivery admission history and physical noteLabor and delivery admission history and physical noteLabor and delivery admission history and physical note: Find: Pt: {Setting}: Doc: {Role}
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP212514-6  Present illness 
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)
 
  现有疾病:历史记录:时间点:^患者:叙述型:现有疾病:历史记录:时间点:^患者:叙述型:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Anamnese der aktuellen Krankheit:Bef:Pkt:^Patient:Nar:BerichtetAnamnese der aktuellen Krankheit:Bef:Pkt:^Patient:Nar:Berichtet
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Malattia attuale:Hx:Pt:^Paziente:Nar:Malattia attuale:Hx:Pt:^Paziente:Nar:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:28 AM
  Long Common Name: History of Present illness Narrative
  Shortname: Hx of Pres illness
  Fully Specified Name: Present illness: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 211
  Status (Raw): ACTIVE


11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Past illness  Hx  Pt  ^Patient  Nar 
  Override Display Name for Form:  History of past illness
  Long Common Name:  History of Past illness Narrative
  Shortname:  Hx of Past illness

TERM DEFINITION/DESCRIPTION(S)
  History of past illness describes the history related to their current complaints, problems, or diagnoses.
 
 

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: 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
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  55169-7   Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0: -: Pt: ^Patient: -:
  57056-4   Labor and delivery admission history and physical noteLabor and delivery admission history and physical noteLabor and delivery admission history and physical note: Find: Pt: {Setting}: Doc: {Role}
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72724-5  Past illness 
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   LP200100-8  Past 
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)
 
  既往病史:历史记录:时间点:^患者:叙述型:既往病史:历史记录:时间点:^患者:叙述型:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Anamnèse. Maladies antérieures:Hx:Temps ponctuel:^Patient:Narratif:Anamnèse. Maladies antérieures:Hx:Temps ponctuel:^Patient:Narratif:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Anamnese früherer Krankheiten:Bef:Pkt:^Patient:Nar:BerichtetAnamnese früherer Krankheiten:Bef:Pkt:^Patient:Nar:Berichtet
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Malattie pregresse:Hx:Pt:^Paziente:Nar:Malattie pregresse:Hx:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  История предыдущих заболеваний:Hx:ТчкВрм:^Пациент:Опис:История предыдущих заболеваний:Hx:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de enfermedades pasadas:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de enfermedades pasadas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:28 AM
  Long Common Name: History of Past illness Narrative
  Shortname: Hx of Past illness
  Fully Specified Name: Past illness: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 1530
  Status (Raw): ACTIVE


56838-6   History of Infectious disease NarrativeHistory of Infectious disease NarrativeInfectious disease: Hx: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Infectious disease  Hx  Pt  ^Patient  Nar 
  Override Display Name for Form:  Coded history of infection
  Long Common Name:  History of Infectious disease Narrative
  Shortname:  Hx of Infectious disease

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Removed "History of" from Component and changed Property from "Find" to "Hx" 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
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57056-4   Labor and delivery admission history and physical noteLabor and delivery admission history and physical noteLabor and delivery admission history and physical note: Find: Pt: {Setting}: Doc: {Role}
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP128526-3  Infectious disease 
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   LP21006-9  Disease 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  传染病:历史记录:时间点:^患者:叙述型:传染病: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)
 
  besmettelijke ziekte:historie:moment:^patiënt:tekstueel:besmettelijke ziekte:historie:moment:^patiënt:tekstueel:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Malattia infettiva:Hx:Pt:^Paziente:Nar:Malattia infettiva:Hx:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Histórico de doenças infecciosas:Achado:Pt:^Paciente:Nar:Histórico de doenças infecciosas:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Инфекционная болезнь:Hx:ТчкВрм:^Пациент:Опис:Инфекционная болезнь:Hx:ТчкВрм:^Пациент:Опис:

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

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:28 AM
  Attachment Units Required: N
  Long Common Name: History of Infectious disease Narrative
  Shortname: Hx of Infectious disease
  Fully Specified Name: Infectious disease: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 50751
  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}
  Override Display Name for Form:  Coded advanced directives
  Long Common Name:  Advance directives
  Shortname:  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.
 
 

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
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  71531-8   ESRD hospitalization panelESRD hospitalization panelHospitalization panel: -: Pt: ^Patient: -: ESRD
  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}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  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}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

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: 12/13/2018 1:28:29 AM
  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


57079-6   Birth plan NarrativeBirth plan NarrativeBirth plan: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Birth plan  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Birth plan
  Long Common Name:  Birth plan Narrative
  Shortname:  Birth plan

TERM DEFINITION/DESCRIPTION(S)
  The Birth Plan section shall contain a narrative description of the patient's requests and expectations with respect to care she is expecting during the labor and delivery process.
 
 

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.29
  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
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP96948-2  Birth plan 
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   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)
 
  出生计划:发现:时间点:^患者:叙述型:出生计划:发现: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)
 
  Nascita, piano:Osservazione:Pt:^Paziente:Nar:Nascita, piano:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Plano de parto:Achado:Pt:^Paciente:Nar:Plano de parto:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Роды план:Находка:ТчкВрм:^Пациент:Опис:Роды план:Находка:ТчкВрм:^Пациент:Опис:

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

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:29 AM
  Attachment Units Required: N
  Long Common Name: Birth plan Narrative
  Shortname: Birth plan
  Fully Specified Name: Birth plan: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 51705
  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 and other adverse reactions
  Long Common Name:  Allergies and adverse reactions Document
  Shortname:  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.
 
 

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
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  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}: -:
  74293-2   Oncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA set: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  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}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  82315-3   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sectionsLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 sectionsLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:
  84429-0   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 set: -: Pt: {Setting}: -:

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:
  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: 12/13/2018 1:28:29 AM
  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


29545-1   Physical findings NarrativePhysical findings NarrativePhysical findings: Find: Pt: ^Patient: Nar: Observed  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Physical findings  Find  Pt  ^Patient  Nar  Observed
  Override Display Name for Form:  Coded physical exam
  Long Common Name:  Physical findings Narrative
  Shortname:  Phys find

BASIC ATTRIBUTES
  Class/Type: H&P.PX/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
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  55169-7   Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0: -: Pt: ^Patient: -:
  57056-4   Labor and delivery admission history and physical noteLabor and delivery admission history and physical noteLabor and delivery admission history and physical note: Find: Pt: {Setting}: Doc: {Role}
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  82315-3   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sectionsLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 sectionsLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 sections: -: Pt: {Setting}: -:
  84429-0   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 set: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73100-7  Physical findings 
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)
 
  体格检查发现:发现:时间点:^患者:叙述型:观察法体格检查发现: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)
 
  Examen physique:Observation:Temps ponctuel:^Patient:Narratif:ObservéExamen physique:Observation:Temps ponctuel:^Patient:Narratif:Observé
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:OsservatoOsservazioni fisiche:Osservazione:Pt:^Paziente:Nar:Osservato
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Achados físicos:Achado:Pt:^Paciente:Nar:ObservadoAchados físicos:Achado:Pt:^Paciente:Nar:Observado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Физикальные находки:Находка:ТчкВрм:^Пациент:Опис:НаблюдённыйФизикальные находки:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  hallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observadohallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:30 AM
  Attachment Units Required: N
  Long Common Name: Physical findings Narrative
  Shortname: Phys find
  Fully Specified Name: Physical findings: Find: Pt: ^Patient: Nar: Observed
     
  Component Word Count: 2
  ID: 21324
  Status (Raw): ACTIVE


10162-6   History of pregnancies NarrativeHistory of pregnancies NarrativeHistory of pregnancies: Hx: Pt: Reproductive system: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
History of pregnancies  Hx  Pt  Reproductive system  Nar 
  Override Display Name for Form:  Pregnancy history
  Long Common Name:  History of pregnancies Narrative
  Shortname:  Pregnancies Hx

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" 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
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57056-4   Labor and delivery admission history and physical noteLabor and delivery admission history and physical noteLabor and delivery admission history and physical note: Find: Pt: {Setting}: Doc: {Role}
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP64609-8  History of pregnancies 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP7555-8  Reproductive system 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP91302-7  History 
Fragments for synonyms   LP100603-2  History of 
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)
 
  妊娠史:历史记录:时间点:生殖系统:叙述型:妊娠史:历史记录:时间点:生殖系统:叙述型:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Anamnèse grossesses:Hx:Temps ponctuel:Système reproducteur:Narratif:Anamnèse grossesses:Hx:Temps ponctuel:Système reproducteur:Narratif:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Anamnese früherer Schwangerschaften:Bef:Pkt:Reproduktionssystem:Nar:BerichtetAnamnese früherer Schwangerschaften:Bef:Pkt:Reproduktionssystem:Nar:Berichtet
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Storia di gravidanze:Hx:Pt:Apparato riproduttivo:Nar:Storia di gravidanze:Hx:Pt:Apparato riproduttivo:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  История беременностей:Hx:ТчкВрм:Репродуктивная система:Опис:История беременностей:Hx:ТчкВрм:Репродуктивная система:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de embarazos:hallazgo:punto en el tiempo:sistema reproductor:Narrativo:informadoantecedentes de embarazos:hallazgo:punto en el tiempo:sistema reproductor:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:30 AM
  Long Common Name: History of pregnancies Narrative
  Shortname: Pregnancies Hx
  Fully Specified Name: History of pregnancies: Hx: Pt: Reproductive system: Nar:
     
  Component Word Count: 3
  ID: 209
  Status (Raw): ACTIVE


57060-6   Estimated date of delivery NarrativeEstimated date of delivery NarrativeEstimated date of delivery: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Estimated date of delivery  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Estimated delivery dates
  Long Common Name:  Estimated date of delivery Narrative
  Shortname:  Est date of delivery

BASIC ATTRIBUTES
  Class/Type: CLIN/Clinical
  First Released in Version: 2.29
  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
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP96930-0  Estimated date of delivery 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Multipart   LP34336-5  Delivery date estimated 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  预产期:发现:时间点:^患者:叙述型:预产期:发现: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)
 
  Data stimata del parto:Osservazione:Pt:^Paziente:Nar:Data stimata del parto:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Data estimada para o parto:Achado:Pt:^Paciente:Nar:Data estimada para o parto:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Предполагаемая дата родоразрешения:Находка:ТчкВрм:^Пациент:Опис:Предполагаемая дата родоразрешения:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  CLIN Finding Random
  EDC Findings Report
  EDD Narrative  
  Est date of delivery Point in time  

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:30 AM
  Attachment Units Required: N
  Long Common Name: Estimated date of delivery Narrative
  Shortname: Est date of delivery
  Fully Specified Name: Estimated date of delivery: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 4
  ID: 51684
  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 
  Override Display Name for Form:  Coded social history
  Long Common Name:  Social history Narrative
  Shortname:  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.
 
 

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
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  55169-7   Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0: -: Pt: ^Patient: -:
  57056-4   Labor and delivery admission history and physical noteLabor and delivery admission history and physical noteLabor and delivery admission history and physical note: Find: Pt: {Setting}: Doc: {Role}
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  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}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  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}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:

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:
  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: 12/13/2018 1:28:31 AM
  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


18610-6   Medication administered SetMedication administered SetMedication.administered: Cmplx: Pt: ^Patient: Set:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Medication.administered  Cmplx  Pt  ^Patient  Set 
  Override Display Name for Form:  Medications administered
  Long Common Name:  Medication administered Set

BASIC ATTRIBUTES
  Class/Type: ATTACH.MEDS/Attachment
  First Released in Version: 1.0l
  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
  34483-8   Medications report requestMedications report requestMedications.report request: Find: Pt: ^Patient: Nom:
  52811-7   HIPAA attachmentsHIPAA attachmentsHIPAA attachments: -: Pt: ^Patient: -:
  57053-1   Nurse Emergency department NoteNurse Emergency department NoteNote: Find: Pt: Emergency department: Doc: Nurse
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP74150-1  Medication.administered 
Property   LP6796-9  Cmplx   [Complex] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7754-7  Set 
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)
 
  药物.已施用的:复合型属性:时间点:^患者:集合型:药物.已施用的:复合型属性:时间点:^患者:集合型:
  French (FRANCE)  (From: ASIP Santé (Agence des systèmes d'information partagés de santé))
 
  Traitement administré:Autre:Ponctuel:Patient:Statut:nullTraitement administré:Autre:Ponctuel:Patient:Statut:nullTraitement administré [Autre] Patient ; Statut
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Farmaco.somminstrato:Cmplx:Pt:^Paziente:Determinato:Farmaco.somminstrato:Cmplx:Pt:^Paziente:Determinato:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Лекарственный препарат.введённый:Кмплкс:ТчкВрм:^Пациент:Множество:Лекарственный препарат.введённый:Кмплкс:ТчкВрм:^Пациент:Множество:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  medicación.administrada:complejo:punto en el tiempo:^paciente:Conjunto:medicación.administrada:complejo:punto en el tiempo:^paciente:Conjunto:

RELATED NAMES
  ATTACH Medication administered Random
  ATTACH.MEDS MEDS  
  Complex Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:31 AM
  Long Common Name: Medication administered Set
  Fully Specified Name: Medication.administered: Cmplx: Pt: ^Patient: Set:
     
  Component Word Count: 2
  ID: 9481
  Status (Raw): ACTIVE


57072-1   Intravenous fluids administered NarrativeIntravenous fluids administered NarrativeIntravenous fluids administered: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Intravenous fluids administered  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Intravenous fluids administered
  Long Common Name:  Intravenous fluids administered Narrative
  Shortname:  IV fluids administered

TERM DEFINITION/DESCRIPTION(S)
  The intravenous fluids administered section shall contain a narrative description of fluids administered to a patient during the course of an encounter.
 
 

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.29
  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
  57053-1   Nurse Emergency department NoteNurse Emergency department NoteNote: Find: Pt: Emergency department: Doc: Nurse
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP96941-7  Intravenous fluids administered 
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   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)
 
  所施用的静脉内液体:发现:时间点:^患者:叙述型:所施用的静脉内液体:发现: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)
 
  Liquidi intravenosi somministrati:Osservazione:Pt:^Paziente:Nar:Liquidi intravenosi somministrati:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Líquidos intravenosos administrados:Achado:Pt:^Paciente:Nar:Líquidos intravenosos administrados:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Внутривенные жидкости введены:Находка:ТчкВрм:^Пациент:Опис:Внутривенные жидкости введены:Находка:ТчкВрм:^Пациент:Опис:

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

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:31 AM
  Attachment Units Required: N
  Long Common Name: Intravenous fluids administered Narrative
  Shortname: IV fluids administered
  Fully Specified Name: Intravenous fluids administered: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 51697
  Status (Raw): ACTIVE


57073-9   Prenatal events NarrativePrenatal events NarrativePrenatal events: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Prenatal events  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Prenatal events
  Long Common Name:  Prenatal events Narrative
  Shortname:  Prenatal events

TERM DEFINITION/DESCRIPTION(S)
  The Prenatal Events Section shall include narrative text describing pertinant prenatal information that has a direct impact on the process of labor and delivery. It shall also include subsections if known.
 
 

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.29
  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
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  62863-6   PhenX domain - Infectious diseases and immunityPhenX domain - Infectious diseases and immunityPhenX domain - Infectious diseases and immunity: -: Pt: ^Patient: -: PhenX

PARTS

Part Type    Part No.  Part Name   
Component   LP96942-5  Prenatal events 
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   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)
 
  产前事件:发现:时间点:^患者:叙述型:产前事件:发现: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)
 
  Eventi prenatali:Osservazione:Pt:^Paziente:Nar:Eventi prenatali:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Eventos pré-natal:Achado:Pt:^Paciente:Nar:Eventos pré-natal:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Пренатальные события:Находка:ТчкВрм:^Пациент:Опис:Пренатальные события:Находка:ТчкВрм:^Пациент:Опис:

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

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:32 AM
  Attachment Units Required: N
  Long Common Name: Prenatal events Narrative
  Shortname: Prenatal events
  Fully Specified Name: Prenatal events: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 51698
  Status (Raw): ACTIVE


10167-5   History of Surgical procedures NarrativeHistory of Surgical procedures NarrativeSurgical procedures: Hx: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical procedures  Hx  Pt  ^Patient  Nar 
  Override Display Name for Form:  List of surgeries
  Long Common Name:  History of Surgical procedures Narrative
  Shortname:  Hx of Surg proc

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
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP212523-7  Surgical procedures 
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   LP100628-9  Surgical 
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)
 
  外科手术操作项目类:历史记录:时间点:^患者:叙述型:外科手术操作项目类: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)
 
  Procedure chirurgiche:Hx:Pt:^Paziente:Nar:Procedure chirurgiche:Hx:Pt:^Paziente:Nar:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de procedimientos quirúrgicos:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de procedimientos quirúrgicos:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:32 AM
  Long Common Name: History of Surgical procedures Narrative
  Shortname: Hx of Surg proc
  Fully Specified Name: Surgical procedures: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 215
  Status (Raw): ACTIVE


57074-7   Labor and delivery process NarrativeLabor and delivery process NarrativeLabor and delivery process: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Labor and delivery process  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Labor and delivery process
  Long Common Name:  Labor and delivery process Narrative
  Shortname:  L&D process

TERM DEFINITION/DESCRIPTION(S)
  The Labor and Delivery Section SHALL include a narrative text containing relevant information collected during the labor and delivery process
 
 

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.29
  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
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP96943-3  Labor and delivery process 
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   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)
 
  临产和分娩过程:发现:时间点:^患者:叙述型:临产和分娩过程:发现: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)
 
  Travaglio e parto, processo:Osservazione:Pt:^Paziente:Nar:Travaglio e parto, processo:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Processo de trabalho e parto:Achado:Pt:^Paciente:Nar:Processo de trabalho e parto:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Роды и родоразрешение процесс:Находка:ТчкВрм:^Пациент:Опис:Роды и родоразрешение процесс:Находка:ТчкВрм:^Пациент:Опис:

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

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:32 AM
  Attachment Units Required: N
  Long Common Name: Labor and delivery process Narrative
  Shortname: L&D process
  Fully Specified Name: Labor and delivery process: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 4
  ID: 51699
  Status (Raw): ACTIVE


57075-4   Newborn delivery information from Newborn NarrativeNewborn delivery information from Newborn NarrativeNewborn delivery information: Find: Pt: ^Newborn: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Newborn delivery information  Find  Pt  ^Newborn  Nar 
  Override Display Name for Form:  Newborn delivery information
  Long Common Name:  Newborn delivery information from Newborn Narrative
  Shortname:  NB delivery info NB

TERM DEFINITION/DESCRIPTION(S)
  The Newborn Delivery Information Section SHALL include a narrative text containing information collected at the birth and up to the transfer of the infant from the birthing room to a post-natal unit.
 
 

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.29
  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
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP96944-1  Newborn delivery information 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP7744-8  Newborn 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 
Fragments for synonyms   LP91459-5  newborn 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  新生儿分娩信息:发现:时间点:^新生儿:叙述型:新生儿分娩信息:发现:时间点:^新生儿:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Neonato, informazioni parto:Osservazione:Pt:^neonato:Nar:Neonato, informazioni parto:Osservazione:Pt:^neonato:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Parto do recém nascido informações:Achado:Pt:^Recem nascido:Nar:Parto do recém nascido informações:Achado:Pt:^Recem nascido:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Новорождённый родоразрешение информация:Находка:ТчкВрм:^новорожденный:Опис:Новорождённый родоразрешение информация:Находка:ТчкВрм:^новорожденный:Опис:

RELATED NAMES
  Finding NB Random
  Findings NB delivery info Report
  H+P New born  
  H+P.PX P prime  
  Narrative Point in time  

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:33 AM
  Attachment Units Required: N
  Long Common Name: Newborn delivery information from Newborn Narrative
  Shortname: NB delivery info NB
  Fully Specified Name: Newborn delivery information: Find: Pt: ^Newborn: Nar:
     
  Component Word Count: 3
  ID: 51701
  Status (Raw): ACTIVE


55103-6   Surgical operation note estimated blood loss NarrativeSurgical operation note estimated blood loss NarrativeSurgical operation note estimated blood loss: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical operation note estimated blood loss  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Estimated blood loss
  Long Common Name:  Surgical operation note estimated blood loss Narrative
  Shortname:  Operative note estimated blood loss

BASIC ATTRIBUTES
  Class/Type: H&P.SURG PROC/Clinical
  First Released in Version: 2.27
  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
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59270-9   Surgical operative note panelSurgical operative note panelSurgical operative note panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73471-2  Surgical operation note estimated blood loss 
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   LP75922-2  P' 
Fragments for synonyms   LP183649-5  note 
Fragments for synonyms   LP100628-9  Surgical 
Fragments for synonyms   LP76273-9  Blood loss 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外科手术记录 预计失血量:发现:时间点:^患者:叙述型:外科手术记录 预计失血量:发现: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)
 
  Nota di operazione chirurgica, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:Nota di operazione chirurgica, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Хирургическая операция запись предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:Хирургическая операция запись предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  Bld loss H+P Point in time
  Blood output H+P.SURGICAL PROCEDURES Random
  Encounter Narrative Report
  Evaluation and management notes Surg
  Evaluation and management note Operative note Visit note
  Finding Operative note estimated blood loss  
  Findings P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:33 AM
  Attachment Units Required: N
  Long Common Name: Surgical operation note estimated blood loss Narrative
  Shortname: Operative note estimated blood loss
  Fully Specified Name: Surgical operation note estimated blood loss: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 6
  ID: 49462
  Status (Raw): ACTIVE


57078-8   Antenatal testing and surveillance NarrativeAntenatal testing and surveillance NarrativeAntenatal testing and surveillance: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Antenatal testing and surveillance  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Coded antenatal testing and surveillance
  Long Common Name:  Antenatal testing and surveillance Narrative
  Shortname:  Antenatal testing & surveillance

TERM DEFINITION/DESCRIPTION(S)
  The Antenatal Testing and Surveillance section shall contain a narrative description of reports and data from tests and surveilllance performed during the pregnancy (e.g. Ultrasound, Biophysicial Profile, Non-Stress Test, Contraction Stress Test)
 
 

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.29
  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
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP96947-4  Antenatal testing and surveillance 
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   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)
 
  出生前测试与监测:发现:时间点:^患者:叙述型:出生前测试与监测:发现: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)
 
  Test e sorveglianza antenatale:Osservazione:Pt:^Paziente:Nar:Test e sorveglianza antenatale:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Teste pré-natal e vigilância:Achado:Pt:^Paciente:Nar:Teste pré-natal e vigilância:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Антенатальное тестирование и надзор:Находка:ТчкВрм:^Пациент:Опис:Антенатальное тестирование и надзор:Находка:ТчкВрм:^Пациент:Опис:

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

CHANGE HISTORY
  Change Type: MIN

WEB CONTENT
  Copyright: Copyright © 2009 IHE International.
 
 

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 1:28:33 AM
  Attachment Units Required: N
  Long Common Name: Antenatal testing and surveillance Narrative
  Shortname: Antenatal testing & surveillance
  Fully Specified Name: Antenatal testing and surveillance: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 4
  ID: 51704
  Status (Raw): ACTIVE