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}: -:  

PANEL HIERARCHY  (view this panel in the LForms viewer)

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  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}: -:    
       51847-2   Assessment+Plan R    
       51848-0   Assessment R    
       18776-5   Plan of care R    
       55109-3   Complications DocumentComplications DocumentComplications: Find: Pt: ^Patient: Doc: R    
       59769-0   Postprocedure diagnosis NarrativePostprocedure diagnosis NarrativePostprocedure diagnosis: Imp: Pt: ^Patient: Nar: R    
       29554-3   Procedure description R    
       59768-2   Procedure indications [Interpretation] NarrativeProcedure indications [Interpretation] NarrativeProcedure indications: Imp: Pt: ^Patient: Nar: R    
       59770-8   Procedure estimated blood loss NarrativeProcedure estimated blood loss NarrativeProcedure estimated blood loss: Find: Pt: ^Patient: Nar: O    
       59771-6   Procedure implants NarrativeProcedure implants NarrativeProcedure implants: Find: Pt: ^Patient: Nar: O    
       59772-4   Planned procedure NarrativePlanned procedure NarrativePlanned procedure: Find: Pt: ^Patient: Nar: O    
       59773-2   Procedure specimens taken NarrativeProcedure specimens taken NarrativeProcedure specimens taken: Find: Pt: ^Patient: Nar: O    
       59774-0   Procedure anesthesia NarrativeProcedure anesthesia NarrativeProcedure anesthesia: Find: Pt: ^Patient: Nar: O    
       59775-7   Procedure disposition NarrativeProcedure disposition NarrativeProcedure disposition: Find: Pt: ^Patient: Nar: O    
       59776-5   Procedure findings NarrativeProcedure findings NarrativeProcedure findings: Find: Pt: ^Patient: Nar: O    
       29545-1   Physical examination R    
       29299-5   Reason for visit C    
       48765-2   Allergies O    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported O    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: O    
       10157-6   Family history O    
       10210-3   General status O    
       11348-0   Past medical history O    
       10160-0   Medications O    
       29549-3   Medication administered NarrativeMedication administered NarrativeMedication administered: Type: Pt: ^Patient: Nar: O    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} O    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: O    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported O    
 

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure note - recommended C-CDA R1.1 sections  Pt  {Setting} 
  Long Common Name:  Procedure note - recommended C-CDA R1.1 sections
  Shortname:  Proced Nte C-CDA R1.1 Sections

TERM DEFINITION/DESCRIPTION(S)
  This panel contains the recommended sections for procedure notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.
 
 

BASIC ATTRIBUTES
  Class/Type: PANEL.DOC/Clinical
  Panel Type: Convenience group
  First Released in Version: 2.32
  Last Updated in Version: 2.56
  Status: Active.
Change Reason: Changed Component name to reflect that this convenience panel contains recommended sections for C-CDA 1.1.

PARTS

Part Type    Part No.  Part Name   
Component   LP157179-5  Procedure note - recommended C-CDA R1.1 sections 
Property   LP6769-6 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP7747-1 
Fragments for synonyms   LP183649-5  note 
Fragments for synonyms   LP20143-1  CDA 
Fragments for synonyms   LP21059-8  Panel 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作记录 - 推荐 CDA 小节:-:时间点:{环境}:-:操作记录 - 推荐 CDA 小节:-:时间点:{环境}:-:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura, nota - set C-CDA R1.1 raccomandato:-:Pt:{Setting}:-:Procedura, nota - set C-CDA R1.1 raccomandato:-:Pt:{Setting}:-:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство запись - рекомендованные CDA разделы:-:ТчкВрм:{Окружение}:-:Вмешательство запись - рекомендованные CDA разделы:-:ТчкВрм:{Окружение}:-:

RELATED NAMES
  Congenital dyserythropoietic anaemia Pan Point in time
  Encounter Panel Proced Nte C-CDA R1.1 Sections
  Evaluation and management PANEL.DOC Random
  Evaluation and management note Panl Visit note
  notes Pnl  

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:15 AM
  Attachment Units Required: N
  Long Common Name: Procedure note - recommended C-CDA R1.1 sections
  Shortname: Proced Nte C-CDA R1.1 Sections
  Fully Specified Name: Procedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
     
  Component Word Count: 7
  ID: 54758
  # of Panel Elements: 28
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



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+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.
 
 

OBSERVATION REQUIRED IN PANEL
Required

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 12:47:16 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


51848-0   Evaluation noteEvaluation noteEvaluation note: Find: Pt: {Setting}: Doc: {Role}  

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

TERM DEFINITION/DESCRIPTION(S)
  An evaluation (also called asessment, impression or diagnoses) note 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.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.24
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  57053-1   Nurse Emergency department NoteNurse Emergency department NoteNote: Find: Pt: Emergency department: Doc: Nurse
  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}: -:
  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}: -:

MEMBER OF THESE EQUIVALENCE GROUPS
  LG38847-6  Evaluation note|ANYRole|ANYSetting
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP74507-2  Evaluation 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   LP21013-5  Evaluation 
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)
 
  评价记录:发现:时间点:{环境}:文档型:{角色}评价记录: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:Osservazione:Pt:{Setting}:Doc:{Role}Valutazione, nota:Osservazione:Pt:{Setting}:Doc:{Role}

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:16 AM
  Attachment Units Required: N
  Long Common Name: Evaluation note
  Shortname: Eval note
  Fully Specified Name: Evaluation note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 2
  ID: 45853
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Plan of care note  Find  Pt  {Setting}  Doc  {Role}
  Override Display Name for Form:  Plan of care
  Long Common Name:  Plan of care note
  Shortname:  Plan of care note

TERM DEFINITION/DESCRIPTION(S)
  Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 1.0l
  Last Updated in Version: 2.63
  HL7 Attachment Structure: IG exists
  Status: Active.
Change Reason: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

ASSOCIATED OBSERVATIONS

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

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

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  57082-0   Antepartum record panelAntepartum record panelAntepartum 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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 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}: -:
  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}: -:

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

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:17 AM
  Long Common Name: Plan of care note
  Shortname: Plan of care note
  Fully Specified Name: Plan of care note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 4
  ID: 9693
  # of Panel Elements: 5
  Status (Raw): ACTIVE


55109-3   Complications DocumentComplications DocumentComplications: Find: Pt: ^Patient: Doc:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Complications  Find  Pt  ^Patient  Doc 
  Long Common Name:  Complications Document
  Shortname:  Complications Doc

TERM DEFINITION/DESCRIPTION(S)
  Information on additional medical problems that develop following a procedure, diagnostic test or study, treatment, or illness.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/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
  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}: -:
  62863-6   PhenX domain - Infectious diseases and immunityPhenX domain - Infectious diseases and immunityPhenX domain - Infectious diseases and immunity: -: Pt: ^Patient: -: PhenX
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72230-6   Diagnostic imaging report - recommended C-CDA R1.1 sectionsDiagnostic imaging report - recommended C-CDA R1.1 sectionsDiagnostic imaging report - 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}: -:
  81220-6   Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sectionsDiagnostic imaging report - recommended C-CDA R2.0 and R2.1 sectionsDiagnostic imaging report - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:
  87416-4   Diagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72306-1  Complications 
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)
 
  并发症:发现:时间点:^患者:文档型:并发症:发现:时间点:^患者:文档型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Complicazioni:Osservazione:Pt:^Paziente:Doc:Complicazioni:Osservazione:Pt:^Paziente:Doc:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Осложнения:Находка:ТчкВрм:^Пациент:Док:Осложнения: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 12:47:17 AM
  Attachment Units Required: N
  Long Common Name: Complications Document
  Shortname: Complications Doc
  Fully Specified Name: Complications: Find: Pt: ^Patient: Doc:
     
  Component Word Count: 1
  ID: 49468
  Status (Raw): ACTIVE


59769-0   Postprocedure diagnosis NarrativePostprocedure diagnosis NarrativePostprocedure diagnosis: Imp: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Postprocedure diagnosis  Imp  Pt  ^Patient  Nar 
  Long Common Name:  Postprocedure diagnosis Narrative
  Shortname:  Postprocedure Dx

TERM DEFINITION/DESCRIPTION(S)
  The Postprocedure Diagnosis section records the diagnosis or diagnoses discovered or confirmed during the procedure.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  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}: -:
  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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100689-1  Postprocedure 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 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作后诊断:印象:时间点:^患者:叙述型:操作后诊断:印象: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)
 
  Diagnosi post procedura:Imp:Pt:^Paziente:Nar:Diagnosi post procedura:Imp:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  После вмешательства диагноз:Впчт:ТчкВрм:^Пациент:Опис:После вмешательства диагноз:Впчт:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC Interp Postprocedure Dx
  Dx Interpretation Random
  Impression MISC Report
  Impression/interpretation of study Narrative  
  Impressions Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:17 AM
  Attachment Units Required: N
  Long Common Name: Postprocedure diagnosis Narrative
  Shortname: Postprocedure Dx
  Fully Specified Name: Postprocedure diagnosis: Imp: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54675
  Status (Raw): ACTIVE


29554-3   Procedure NarrativeProcedure NarrativeProcedure: Type: Pt: ^Patient: Nar:  

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

TERM DEFINITION/DESCRIPTION(S)
  Procedure records the descriptions of the procedure with an extensive narrative and may include procedure site preparation, pertinent details related to measurements and markings, procedure times, instrumentation, and vital signs and other monitoring data.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.03
  Last Updated in Version: 2.40
  Status: Active

MEMBER OF THESE PANELS
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:
  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}: -:
  84907-5   Cancer pathology panel - Colorectal cancer specimenCancer pathology panel - Colorectal cancer specimenCancer pathology panel: -: Pt: Colorectal cancer specimen: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73191-6  Procedure 
Property   LP6886-8  Type 
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)
 
  操作项目:类型:时间点:^患者:叙述型:操作项目:类型: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)
 
  Procedura:Tipo:Pt:^Paziente:Nar:Procedura:Tipo:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Procedimento:Tipo:Pt:^Paciente:Nar:Procedimento:Tipo:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство:Тип:ТчкВрм:^Пациент:Опис:Вмешательство:Тип:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  procedimiento:tipo:punto en el tiempo:^paciente:Narrativo:procedimiento:tipo:punto en el tiempo:^paciente:Narrativo:
  Spanish (SPAIN)  (From: Regenstrief-generated full translation based on part translation provided by the Clinical Laboratory Committee of SERVICIO EXTREMEÑO DE SALUD, with the support of BITAC MAP.)
 
  Procedimiento:Tipo:Punto temporal:^paciente:Narrativo:Procedimiento:Tipo:Punto temporal:^paciente:Narrativo:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:18 AM
  Attachment Units Required: N
  Long Common Name: Procedure Narrative
  Shortname: Procedure
  Fully Specified Name: Procedure: Type: Pt: ^Patient: Nar:
     
  Component Word Count: 1
  ID: 21335
  Status (Raw): ACTIVE


59768-2   Procedure indications [Interpretation] NarrativeProcedure indications [Interpretation] NarrativeProcedure indications: Imp: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure indications  Imp  Pt  ^Patient  Nar 
  Long Common Name:  Procedure indications [Interpretation] Narrative
  Shortname:  Procedure indications Imp

TERM DEFINITION/DESCRIPTION(S)
  The Procedure indications section records details about the reason for the procedure, treatment or service.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:
  87416-4   Diagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100852-5  Procedure indications 
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 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作适应症:印象:时间点:^患者:叙述型:操作适应症:印象: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)
 
  Procedura, indicazioni:Imp:Pt:^Paziente:Nar:Procedura, indicazioni:Imp:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство показания:Впчт:ТчкВрм:^Пациент:Опис:Вмешательство показания:Впчт:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC Interp Point in time
  Impression Interpretation Random
  Impression/interpretation of study MISC Report
  Impressions Narrative  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:18 AM
  Attachment Units Required: N
  Long Common Name: Procedure indications [Interpretation] Narrative
  Shortname: Procedure indications Imp
  Fully Specified Name: Procedure indications: Imp: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54674
  Status (Raw): ACTIVE


59770-8   Procedure estimated blood loss NarrativeProcedure estimated blood loss NarrativeProcedure estimated blood loss: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure estimated blood loss  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure estimated blood loss Narrative
  Shortname:  Estimated blood loss

TERM DEFINITION/DESCRIPTION(S)
  Procedure estimated blood loss is the approximate amount of blood that the patient lost during the procedure or surgery. It may be an accurate quantitative amount, e.g., 250 milliliters, or it may be descriptive, e.g., "minimal" or "none".
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100690-9  Procedure 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   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)
 
  操作预计失血量:发现:时间点:^患者:叙述型:操作预计失血量: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)
 
  Procedura, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:Procedura, 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)
 
  Вмешательство предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:Вмешательство предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  Bld loss Findings Random
  Blood output MISC Report
  DOC.MISC Narrative  
  Finding Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:18 AM
  Attachment Units Required: N
  Long Common Name: Procedure estimated blood loss Narrative
  Shortname: Estimated blood loss
  Fully Specified Name: Procedure estimated blood loss: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 4
  ID: 54676
  Status (Raw): ACTIVE


59771-6   Procedure implants NarrativeProcedure implants NarrativeProcedure implants: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure implants  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure implants Narrative
  Shortname:  Implants

TERM DEFINITION/DESCRIPTION(S)
  The Procedure implants section records any materials placed during a procedure including stents, tubes, and drains.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100691-7  Procedure implants 
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)
 
  操作植入物:发现:时间点:^患者:叙述型:操作植入物: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)
 
  Procedura impianti:Osservazione:Pt:^Paziente:Nar:Procedura impianti:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство импланты:Находка:ТчкВрм:^Пациент:Опис:Вмешательство импланты:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:19 AM
  Attachment Units Required: N
  Long Common Name: Procedure implants Narrative
  Shortname: Implants
  Fully Specified Name: Procedure implants: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54677
  Status (Raw): ACTIVE


59772-4   Planned procedure NarrativePlanned procedure NarrativePlanned procedure: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Planned procedure  Find  Pt  ^Patient  Nar 
  Long Common Name:  Planned procedure Narrative
  Shortname:  Planned procedure

TERM DEFINITION/DESCRIPTION(S)
  The Planned Procedure section records the procedure(s) that the clinician thought would be needed based on the pre-procedure assessment.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100692-5  Planned procedure 
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)
 
  所计划的操作:发现:时间点:^患者:叙述型:所计划的操作: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)
 
  Procedura prevista:Osservazione:Pt:^Paziente:Nar:Procedura prevista:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Запланированное вмешательство:Находка:ТчкВрм:^Пациент:Опис:Запланированное вмешательство:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:19 AM
  Attachment Units Required: N
  Long Common Name: Planned procedure Narrative
  Shortname: Planned procedure
  Fully Specified Name: Planned procedure: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54678
  Status (Raw): ACTIVE


59773-2   Procedure specimens taken NarrativeProcedure specimens taken NarrativeProcedure specimens taken: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure specimens taken  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure specimens taken Narrative
  Shortname:  Specimens taken

TERM DEFINITION/DESCRIPTION(S)
  The Procedure specimens taken section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis. The narrative may include a description of the specimens.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100693-3  Procedure specimens taken 
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)
 
  已采集的操作标本:发现:时间点:^患者:叙述型:已采集的操作标本: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)
 
  Procedura, campioni prelevati:Osservazione:Pt:^Paziente:Nar:Procedura, campioni prelevati:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство образцы изъятые:Находка:ТчкВрм:^Пациент:Опис:Вмешательство образцы изъятые:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:19 AM
  Attachment Units Required: N
  Long Common Name: Procedure specimens taken Narrative
  Shortname: Specimens taken
  Fully Specified Name: Procedure specimens taken: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 54679
  Status (Raw): ACTIVE


59774-0   Procedure anesthesia NarrativeProcedure anesthesia NarrativeProcedure anesthesia: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure anesthesia  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure anesthesia Narrative
  Shortname:  Anesthesia

TERM DEFINITION/DESCRIPTION(S)
  The Anesthesia section briefly records the type of anesthesia (e.g., general, conscious, or local) and may state the actual agent(s) used.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100694-1  Procedure anesthesia 
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)
 
  操作麻醉:发现:时间点:^患者:叙述型:操作麻醉: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)
 
  Procedura anestesia:Osservazione:Pt:^Paziente:Nar:Procedura anestesia:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство анестезия:Находка:ТчкВрм:^Пациент:Опис:Вмешательство анестезия:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:20 AM
  Attachment Units Required: N
  Long Common Name: Procedure anesthesia Narrative
  Shortname: Anesthesia
  Fully Specified Name: Procedure anesthesia: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54681
  Status (Raw): ACTIVE


59775-7   Procedure disposition NarrativeProcedure disposition NarrativeProcedure disposition: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure disposition  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure disposition Narrative
  Shortname:  Disposition

TERM DEFINITION/DESCRIPTION(S)
  The Procedure disposition section records the status and condition of the patient at the completion of the procedure or surgery. It often also states where the patent was transferred to for the next level of care.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100695-8  Procedure disposition 
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)
 
  操作处置:发现:时间点:^患者:叙述型:操作处置: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)
 
  Procedura, disposizione:Osservazione:Pt:^Paziente:Nar:Procedura, disposizione:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство диспозиция:Находка:ТчкВрм:^Пациент:Опис:Вмешательство диспозиция:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:20 AM
  Attachment Units Required: N
  Long Common Name: Procedure disposition Narrative
  Shortname: Disposition
  Fully Specified Name: Procedure disposition: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54682
  Status (Raw): ACTIVE


59776-5   Procedure findings NarrativeProcedure findings NarrativeProcedure findings: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure findings  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure findings Narrative
  Shortname:  Findings

TERM DEFINITION/DESCRIPTION(S)
  The Procedure findings section records clinically significant observations confirmed or discovered during a procedure, treatment or service.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  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
  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}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & 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}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation 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}: -:
  87416-4   Diagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100696-6  Procedure findings 
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)
 
  操作发现:发现:时间点:^患者:叙述型:操作发现: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)
 
  Procedura, osservazioni:Osservazione:Pt:^Paziente:Nar:Procedura, osservazioni:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство находки:Находка:ТчкВрм:^Пациент:Опис:Вмешательство находки:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:20 AM
  Attachment Units Required: N
  Long Common Name: Procedure findings Narrative
  Shortname: Findings
  Fully Specified Name: Procedure findings: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54683
  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:  Physical examination
  Long Common Name:  Physical findings Narrative
  Shortname:  Phys find

OBSERVATION REQUIRED IN PANEL
Required

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 12:47:20 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


29299-5   Reason for visit NarrativeReason for visit NarrativeReason for visit: Find: Pt: ^Patient: Nar:  

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

TERM DEFINITION/DESCRIPTION(S)
  This section records the patient's reason for their visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
 
 

OBSERVATION REQUIRED IN PANEL
Conditional

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
  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: -:
  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}: -:
  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: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73240-1  Reason for visit 
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)
 
  关于就诊的原因:发现:时间点:^患者:叙述型:关于就诊的原因: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)
 
  Raison de consultation:Observation:Temps ponctuel:^Patient:Narratif:Raison de consultation:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Motivo della visita:Osservazione:Pt:^Paziente:Nar:Motivo della visita:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Motivo da visita:Achado:Pt:^Paciente:Nar:Motivo da visita:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Причина визит:Находка:ТчкВрм:^Пациент:Опис:Причина визит:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  motivo de la consulta:hallazgo:punto en el tiempo:^paciente:Narrativo:motivo de la consulta:hallazgo:punto en el tiempo:^paciente:Narrativo:

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 12:47:21 AM
  Attachment Units Required: N
  Long Common Name: Reason for visit Narrative
  Shortname: Reason for visit
  Fully Specified Name: Reason for visit: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 21054
  Status (Raw): ACTIVE


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

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

OBSERVATION REQUIRED IN PANEL
Optional

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 12:47:21 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


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
  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).
 
 

OBSERVATION REQUIRED IN PANEL
Optional

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 12:47:21 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


46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Chief complaint+Reason for visit  Find  Pt  ^Patient  Nar 
  Long Common Name:  Chief complaint+Reason for visit Narrative
  Shortname:  Chief complaint+Reason for visit

TERM DEFINITION/DESCRIPTION(S)
  This term is used to record the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

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.

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: -:
  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}: -:
  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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72245-1  Chief complaint+Reason for visit 
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)
 
  主诉+​就诊原因:发现:时间点:^患者:叙述型:主诉+​就诊原因: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)
 
  Plainte principale+​raison de visite:Observation:Temps ponctuel:^Patient:Narratif:Plainte principale+​raison de visite:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Disturbo principale+​Motivo dell'incontro:Osservazione:Pt:^Paziente:Nar:Disturbo principale+​Motivo dell'incontro:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Reclamação à chefia+​Motivo da visita:Achado:Pt:^Paciente:Nar:Reclamação à chefia+​Motivo da visita:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Основная жалоба+​Причина визита:Находка:ТчкВрм:^Пациент:Опис:Основная жалоба+​Причина визита:Находка:ТчкВрм:^Пациент:Опис:

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 12:47:22 AM
  Attachment Units Required: N
  Long Common Name: Chief complaint+Reason for visit Narrative
  Shortname: Chief complaint+Reason for visit
  Fully Specified Name: Chief complaint+Reason for visit: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 5
  ID: 39659
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
History of family member diseases  Hx  Pt  ^Family member  Nar 
  Override Display Name for Form:  Family history
  Long Common Name:  History of family member diseases Narrative
  Shortname:  Family member diseases Hx

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

OBSERVATION REQUIRED IN PANEL
Optional

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

MEMBER OF THESE PANELS
  35089-2   History and physical panelHistory and physical panelHistory and physical panel: -: Pt: ^Patient: -:
  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}
  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}: -:
  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}: -:
  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: -:
  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}: -:

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:22 AM
  Long Common Name: History of family member diseases Narrative
  Shortname: Family member diseases Hx
  Fully Specified Name: History of family member diseases: Hx: Pt: ^Family member: Nar:
     
  Component Word Count: 5
  ID: 203
  Status (Raw): ACTIVE


10210-3   Physical findings of General status NarrativePhysical findings of General status NarrativePhysical findings: Find: Pt: General status: Nar: Observed  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Physical findings  Find  Pt  General status  Nar  Observed
  Override Display Name for Form:  General status
  Long Common Name:  Physical findings of General status Narrative
  Shortname:  Phys find General status

TERM DEFINITION/DESCRIPTION(S)
  Physical findings (of general status) describes general observations and readily observable attributes of the patient, including affect and demeanor, apparent age compared to actual age, gender, ethnicity, nutritional status based on appearance, body build and habitus (e.g., muscular, cachectic, obese), developmental or other deformities, gait and mobility, personal hygiene, evidence of distress, and voice quality and speech.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: H&P.PX/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: -:
  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}: -:
  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}: -:
  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}: -:

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)] 
System   LP29998-9  General status 
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:一般状态:叙述型:观察法体格检查发现:发现:时间点:一般状态:叙述型:观察法
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Osservazioni fisiche:Osservazione:Pt:Stato generale:Nar:OsservatoOsservazioni fisiche:Osservazione:Pt:Stato generale:Nar:Osservato
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Achados físicos:Achado:Pt:Estado geral:Nar:ObservadoAchados físicos:Achado:Pt:Estado geral:Nar:Observado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Физикальные находки:Находка:ТчкВрм:Общий статус:Опис:НаблюдённыйФизикальные находки:Находка:ТчкВрм:Общий статус:Опис:Наблюдённый
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  hallazgos físicos:hallazgo:punto en el tiempo:estado general:Narrativo:observadohallazgos físicos:hallazgo:punto en el tiempo:estado general: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 12:47:22 AM
  Long Common Name: Physical findings of General status Narrative
  Shortname: Phys find General status
  Fully Specified Name: Physical findings: Find: Pt: General status: Nar: Observed
     
  Component Word Count: 2
  ID: 262
  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:  Past medical history
  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.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

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 12:47:23 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


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:  Medications
  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.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

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 12:47:23 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


29549-3   Medication administered NarrativeMedication administered NarrativeMedication administered: Type: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Medication administered  Type  Pt  ^Patient  Nar 
  Long Common Name:  Medication administered Narrative
  Shortname:  Medication administered

TERM DEFINITION/DESCRIPTION(S)
  Medications administered defines medications and fluids administered during the procedure, excluding anesthetic medications. Medications administered for anesthesia are typically documented in the section on Anesthesia.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.03
  Last Updated in Version: 2.40
  Status: Active

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: -:
  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}: -:
  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}: -:
  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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72926-6  Medication administered 
Property   LP6886-8  Type 
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)
 
  已施用的药物:类型:时间点:^患者:叙述型:已施用的药物:类型: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)
 
  Médicaments administrés:Type:Temps ponctuel:^Patient:Narratif:Médicaments administrés:Type:Temps ponctuel:^Patient:Narratif:
  French (CANADA)  (From: Regenstrief-generated full translation based on part translation provided by Canada Health Infoway Inc.)
 
  Médicaments administrés:Type:Temps ponctuel:^Patient:Narratif:Médicaments administrés:Type:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Farmaco somministrato:Tipo:Pt:^Paziente:Nar:Farmaco somministrato:Tipo:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Medicação administrada:Tipo:Pt:^Paciente:Nar:Medicação administrada:Tipo:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Лекарственный препарат введён:Тип:ТчкВрм:^Пациент:Опис:Лекарственный препарат введён:Тип:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  medicación administrada:tipo:punto en el tiempo:^paciente:Narrativo:medicación administrada:tipo:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  H+P Narrative Random
  H+P.PX P prime Report
  Medication.administered Point in time Typ

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:23 AM
  Attachment Units Required: N
  Long Common Name: Medication administered Narrative
  Shortname: Medication administered
  Fully Specified Name: Medication administered: Type: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 21329
  Status (Raw): ACTIVE


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

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

TERM DEFINITION/DESCRIPTION(S)
  This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically and at the time the document is generated.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 2.19
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  57053-1   Nurse Emergency department NoteNurse Emergency department NoteNote: Find: Pt: Emergency department: Doc: Nurse
  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}: -:
  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}: -:
  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}: -:
  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   LP72725-2  History of Procedures 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP75922-2  P' 
Fragments for synonyms   LP91302-7  History 
Fragments for synonyms   LP100603-2  History of 

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/13/2018 12:47:24 AM
  Attachment Units Required: N
  Long Common Name: History of Procedures Document
  Shortname: Procedures Hx Doc
  Fully Specified Name: History of procedures: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 3
  ID: 41048
  Status (Raw): ACTIVE


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

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

OBSERVATION REQUIRED IN PANEL
Optional

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 12:47:24 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


10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Review of systems  Find  Pt  ^Patient  Nar  Reported
  Long Common Name:  Review of systems Narrative - Reported
  Shortname:  Review of systems

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

OBSERVATION REQUIRED IN PANEL
Optional

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}
  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}: -:
  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}: -:
  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}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73297-1  Review of systems 
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)
 
  系统评审:发现:时间点:^患者:叙述型:报告法系统评审: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)
 
  Revue des systèmes:Observation:Temps ponctuel:^Patient:Narratif:RapportéRevue des systèmes:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Esame di apparati:Osservazione:Pt:^Paziente:Nar:RiportatoEsame di apparati:Osservazione:Pt:^Paziente:Nar:Riportato
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Исследование по системам:Находка:ТчкВрм:^Пациент:Опис:СообщенныйИсследование по системам:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  revisión de sistemas:hallazgo:punto en el tiempo:^paciente:Narrativo:informadorevisión de sistemas: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 12:47:24 AM
  Long Common Name: Review of systems Narrative - Reported
  Shortname: Review of systems
  Fully Specified Name: Review of systems: Find: Pt: ^Patient: Nar: Reported
     
  Component Word Count: 3
  ID: 237
  Status (Raw): ACTIVE