69459-6  Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:  

PANEL HIERARCHY  (view this panel in the LForms viewer)

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:    
       34133-9   Summarization of episode note R    
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: O    
       46241-6   Hospital admission diagnosis Narrative - ReportedHospital admission diagnosis Narrative - ReportedHospital admission Dx: Imp: Pt: ^Patient: Nar: Reported O    
       11535-2   Hospital discharge Dx O    
       11450-4   Problem list R    
       10155-0   History of allergies (Nar) R    
       8658-7   History of allergies (Nom) R    
       11382-9   Medication allergy - ReportedMedication allergy - ReportedMedication allergy: Hx: Pt: ^Patient: Nom: Reported O    
       10160-0   History of medication use O    
       10183-2   Hospital discharge medications O    
       42346-7   Medications on admission (narrative)Medications on admission (narrative)Medications on admission: Find: Pt: ^Patient: Nar: O    
       8648-8   Hospital course O    
       10154-3   Chief complaint O    
       29299-5   Reason for visit O    
       46239-0   Reason for visit and Chief complaint O    
       42349-1   Reason for referral O    
       42348-3   Advanced directives O    
       10164-2   History of present illness O    
       10158-4   History of Functional status NarrativeHistory of Functional status NarrativeFunctional status: Hx: Pt: ^Patient: Nar: O    
       10157-6   History of family member diseases O    
       29762-2   Social history O    
       11369-6   History of immunizations O    
       10167-5   History of surgical procedures O    
       46240-8   History of hospitalizations+History of outpatient visits O    
       11336-5   History of hospitalizations O    
       11346-4   History of outpatient visits O    
       10187-3   Review of systems O    
       10184-0   Hospital discharge physical O    
       22029-3   Physical exam.total O    
       8716-3   Vital signs, physical findings O    
       46242-4   Vital signs, fetus O    
       11493-4   Hospital discharge studies summary O    
       30954-2   Relevant diagnostic tests and/or laboratory data O    
       18776-5   Plan of care O    
 

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Care record summary panel  Pt  ^Patient 
  Long Common Name:  Care record summary panel
  Shortname:  CRS Pnl

TERM DEFINITION/DESCRIPTION(S)
  The panel term was created for the HL7 Care Record Summary (CRS) (US realm) document, which is based on HL7 CDA Release 2.0.
 
 

BASIC ATTRIBUTES
  Class/Type: PANEL.DOC/Clinical
  Panel Type: Panel
  First Released in Version: 2.38
  Last Updated in Version: 2.50
  Order vs. Obs.: Order
  Status: Active

PARTS

Part Type    Part No.  Part Name   
Component   LP136277-3  Care record summary panel 
Property   LP6769-6 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Fragments for synonyms   LP21059-8  Panel 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  医疗护理记录摘要组套:-:时间点:^患者:-:医疗护理记录摘要组套:-:时间点:^患者:-:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Prospetto documento di cura, panel:-:Pt:^Paziente:-:Prospetto documento di cura, panel:-:Pt:^Paziente:-:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Помощь запись краткие сведения панель:-:ТчкВрм:^Пациент:-:Помощь запись краткие сведения панель:-:ТчкВрм:^Пациент:-:

RELATED NAMES
  CRS Pnl Panl Random
  Pan Pnl  
  PANEL.DOC Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:14 PM
  Attachment Units Required: N
  Long Common Name: Care record summary panel
  Shortname: CRS Pnl
  Fully Specified Name: Care record summary panel: -: Pt: ^Patient: -:
     
  Component Word Count: 4
  ID: 68773
  # of Panel Elements: 35
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



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

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

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

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

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.09
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  HL7 Attachment Structure: IG exists
  Status: Active.
Change Reason: Changed Component from 'Summarization of episode' per Clinical LOINC Committee decision to harmonize existing Document Ontology axes values.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

ASSOCIATED OBSERVATIONS

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

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

ASSOCIATED OBSERVATIONS

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

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

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  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}: -:

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

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:16 PM
  Attachment Units Required: N
  Long Common Name: Summary of episode note
  Shortname: Summary of episode note
  Fully Specified Name: Summary of episode note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 4
  ID: 26456
  # of Panel Elements: 16
  Status (Raw): ACTIVE


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 
  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: 12/12/2018 9:55:16 PM
  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


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

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

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.

EXAMPLE ANSWERS
  Cholecystitis

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

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:16 PM
  Attachment Units Required: N
  Long Common Name: Hospital admission diagnosis Narrative - Reported
  Shortname: Hospital admission Dx Reported
  Fully Specified Name: Hospital admission Dx: Imp: Pt: ^Patient: Nar: Reported
     
  Component Word Count: 3
  ID: 39661
  Status (Raw): ACTIVE


11535-2   Hospital discharge Dx NarrativeHospital discharge Dx NarrativeHospital discharge Dx: Imp: Pt: ^Patient: Nar:  

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

TERM DEFINITION/DESCRIPTION(S)
  Hospital discharge diagnosis describes the patient's relevant problems or diagnoses that occurred during the hospitalization or that need to be followed after hospitalization.
 
 

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
  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
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72750-0  Hospital discharge Dx 
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 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP30831-9  Dx 
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)
 
  医院出院诊断:印象:时间点:^患者:叙述型:医院出院诊断:印象: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)
 
  Documents sortie hôpital:Impression/​interprétation d'étude:Temps ponctuel:^Patient:Narratif:Documents sortie hôpital:Impression/​interprétation d'étude:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Dimissione ospedaliera, Dx:Imp:Pt:^Paziente:Nar:Dimissione ospedaliera, Dx:Imp:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Alta hospitalar Dx:Imp:Pt:^Paciente:Nar:Alta hospitalar Dx:Imp:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Госпитализация выбытие Dx:Впчт:ТчкВрм:^Пациент:Опис:Госпитализация выбытие Dx:Впчт:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  diagnóstico al alta del hospital:impresión/​interpretación del estudio:punto en el tiempo:^paciente:Narrativo:diagnóstico al alta del hospital:impresión/​interpretación del estudio:punto en el tiempo:^paciente:Narrativo:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:17 PM
  Long Common Name: Hospital discharge Dx Narrative
  Shortname: Hospital discharge Dx
  Fully Specified Name: Hospital discharge Dx: Imp: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 1705
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Problem list  Find  Pt  ^Patient  Nom  Reported
  Override Display Name for Form:  Problem list
  Long Common Name:  Problem list - Reported
  Shortname:  Problem list Reported

OBSERVATION REQUIRED IN PANEL
Required

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

MEMBER OF THESE PANELS
  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: -:
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  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}: -:
  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}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:17 PM
  Long Common Name: Problem list - Reported
  Shortname: Problem list Reported
  Fully Specified Name: Problem list: Find: Pt: ^Patient: Nom: Reported
     
  Component Word Count: 2
  ID: 1642
  Status (Raw): ACTIVE


10155-0   History of allergies, reportedHistory of allergies, reportedAllergies: Hx: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Allergies  Hx  Pt  ^Patient  Nar 
  Override Display Name for Form:  History of allergies (Nar)
  Long Common Name:  History of allergies, reported
  Shortname:  Hx of Allergies

OBSERVATION REQUIRED IN PANEL
Required

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

MEMBER OF THESE PANELS
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72062-3   Medication allergies panel [ESRD]Medication allergies panel [ESRD]Medication allergies panel: -: Pt: ^Patient: -: ESRD

PARTS

Part Type    Part No.  Part Name   
Component   LP74464-6  Allergies 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  变态反应:历史记录:时间点:^患者:叙述型:变态反应:历史记录:时间点:^患者:叙述型:
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  allergieën:historie:moment:^patiënt:tekstueel:allergieën:historie:moment:^patiënt:tekstueel:
  French (CANADA)  (From: Regenstrief-generated full translation based on part translation provided by Canada Health Infoway Inc.)
 
  Allergies:Histoire:Temps ponctuel:^Patient:Narratif:Allergies:Histoire:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Allergie:Hx:Pt:^Paziente:Nar:Allergie:Hx:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Аллергии:Hx:ТчкВрм:^Пациент:Опис:Аллергии:Hx:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de alergias:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de alergias: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: 12/12/2018 9:55:17 PM
  Long Common Name: History of allergies, reported
  Shortname: Hx of Allergies
  Fully Specified Name: Allergies: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 1
  ID: 132
  Status (Raw): ACTIVE


8658-7   History of AllergiesHistory of AllergiesAllergies: Hx: Pt: ^Patient: Nom:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Allergies  Hx  Pt  ^Patient  Nom 
  Override Display Name for Form:  History of allergies (Nom)
  Long Common Name:  History of Allergies
  Shortname:  Hx of Allergies

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0h(3)
  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
  35089-2   History and physical panelHistory and physical panelHistory and physical panel: -: Pt: ^Patient: -:
  35090-0   Patient historyPatient historyPatient history: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP74464-6  Allergies 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
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)
 
  变态反应:历史记录:时间点:^患者:名义型:变态反应:历史记录:时间点:^患者:名义型:
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  allergieën:historie:moment:^patiënt:nominaal:allergieën:historie:moment:^patiënt:nominaal:
  French (CANADA)  (From: Regenstrief-generated full translation based on part translation provided by Canada Health Infoway Inc.)
 
  Allergies:Histoire:Temps ponctuel:^Patient:Nominal:Allergies:Histoire:Temps ponctuel:^Patient:Nominal:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Allergie:Hx:Pt:^Paziente:Nom:Allergie:Hx:Pt:^Paziente:Nom:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Histórico de alergias:Achado:Pt:^Paciente:Nom:RelatadoHistórico de alergias:Achado:Pt:^Paciente:Nom:Relatado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Аллергии:Hx:ТчкВрм:^Пациент:Ном:Аллергии:Hx:ТчкВрм:^Пациент:Ном:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de alergias:hallazgo:punto en el tiempo:^paciente:Nominal:informadoantecedentes de alergias:hallazgo:punto en el tiempo:^paciente:Nominal:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:17 PM
  Long Common Name: History of Allergies
  Shortname: Hx of Allergies
  Fully Specified Name: Allergies: Hx: Pt: ^Patient: Nom:
     
  Component Word Count: 1
  ID: 65361
  Status (Raw): ACTIVE


11382-9   Medication allergy - ReportedMedication allergy - ReportedMedication allergy: Hx: Pt: ^Patient: Nom: Reported  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Medication allergy  Hx  Pt  ^Patient  Nom  Reported
  Long Common Name:  Medication allergy - Reported
  Shortname:  Medication allergy Reported

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0j-a
  Last Updated in Version: 2.27
  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: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  89070-7   ADAPTABLE patient reported item set [ADAPTABLE]ADAPTABLE patient reported item set [ADAPTABLE]ADAPTABLE patient reported item set: -: Pt: ^Patient: -: ADAPTABLE

PARTS

Part Type    Part No.  Part Name   
Component   LP72928-2  Medication allergy 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP6486-7  Reported 
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)
 
  药物变态反应:历史记录:时间点:^患者:名义型:报告法药物变态反应:历史记录:时间点:^患者:名义型:报告法
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Allergies médicaments:Hx:Temps ponctuel:^Patient:Nominal:RapportéAllergies médicaments:Hx:Temps ponctuel:^Patient:Nominal:Rapporté
  French (CANADA)  (From: Regenstrief-generated full translation based on part translation provided by Canada Health Infoway Inc.)
 
  Médicaments allergie:Histoire:Temps ponctuel:^Patient:Nominal:RapportéMédicaments allergie:Histoire:Temps ponctuel:^Patient:Nominal:Rapporté
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Allergia ai farmaci:Hx:Pt:^Paziente:Nom:RiportatoAllergia ai farmaci:Hx:Pt:^Paziente:Nom:Riportato
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Alergia a medicação:Hx:Pt:^Paciente:Nom:RelatadoAlergia a medicação:Hx:Pt:^Paciente:Nom:Relatado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Лекарственный препарат аллергия:Hx:ТчкВрм:^Пациент:Ном:СообщенныйЛекарственный препарат аллергия:Hx:ТчкВрм:^Пациент:Ном:Сообщенный
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  alergia a la medicación:antecedentes:punto en el tiempo:^paciente:Nominal:informadoalergia a la medicación:antecedentes:punto en el tiempo:^paciente:Nominal:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:18 PM
  Long Common Name: Medication allergy - Reported
  Shortname: Medication allergy Reported
  Fully Specified Name: Medication allergy: Hx: Pt: ^Patient: Nom: Reported
     
  Component Word Count: 2
  ID: 1567
  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:  History of medication use
  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: 12/12/2018 9:55:18 PM
  Long Common Name: History of Medication use Narrative
  Shortname: Hx of Medication use
  Fully Specified Name: Medication use: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 207
  Status (Raw): ACTIVE


10183-2   Hospital discharge medications NarrativeHospital discharge medications NarrativeHospital discharge medications: Find: Pt: ^Patient: Nar:  

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

TERM DEFINITION/DESCRIPTION(S)
  Hospital discharge medications defines the medications that the patient is intended to take (or stop) after discharge. This may also include a patient's prescription history and indicate the source of the medication list, for example, from a pharmacy system versus from the patient.
 
 

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
  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: -:
  59271-7   Hospital discharge summary panelHospital discharge summary panelHospital discharge summary panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  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}: -:
  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   LP72754-2  Hospital discharge medications 
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   LP100598-4  Discharge 
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)
 
  医院出院药物:发现:时间点:^患者:叙述型:医院出院药物: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)
 
  Médications sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:Médications sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Dimissione ospedaliera, farmaci:Osservazione:Pt:^Paziente:Nar:Dimissione ospedaliera, farmaci:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Госпитализация выбытие лекарственные препараты:Находка:ТчкВрм:^Пациент:Опис:Госпитализация выбытие лекарственные препараты:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  medicación para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:medicación para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Disch H+P Point in time
  discharge medication H+P.HX Random
  Discharge meds Hosp Report
  Finding Narrative  
  Findings P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:18 PM
  Long Common Name: Hospital discharge medications Narrative
  Shortname: Hospital discharge medications
  Fully Specified Name: Hospital discharge medications: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 233
  Status (Raw): ACTIVE


42346-7   Medications on admission (narrative)Medications on admission (narrative)Medications on admission: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Medications on admission  Find  Pt  ^Patient  Nar 
  Long Common Name:  Medications on admission (narrative)

TERM DEFINITION/DESCRIPTION(S)
  Admission can refer to hospital admission, long-term care admission, or home health admission.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: ATTACH.CLINRPT/Attachment
  First Released in Version: 2.16
  Last Updated in Version: 2.27
  Status: Active

MEMBER OF THESE PANELS
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  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}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP74153-5  Medications on admission 
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)
 
  入院时的药物:发现:时间点:^患者:叙述型:入院时的药物: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)
 
  Médications à admission:Observation:Temps ponctuel:^Patient:Narratif:Médications à admission:Observation:Temps ponctuel:^Patient:Narratif:
  French (FRANCE)  (From: ASIP Santé (Agence des systèmes d'information partagés de santé))
 
  Traitement lors de l'admission:Recherche:Ponctuel:Patient:Commentaire:nullTraitement lors de l'admission:Recherche:Ponctuel:Patient:Commentaire:nullTraitement lors de l'admission [Recherche] Patient ; Commentaire
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Farmaci al ricovero:Osservazione:Pt:^Paziente:Nar:Farmaci al ricovero:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Medicamentos na internação:Achado:Pt:^Paciente:Nar:Medicamentos na internação:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Лекарственные препараты при госпитализации:Находка:ТчкВрм:^Пациент:Опис:Лекарственные препараты при госпитализации:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  ATTACH Findings Random
  ATTACH.CLINRPT Narrative Report
  Finding Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:19 PM
  Attachment Units Required: N
  Long Common Name: Medications on admission (narrative)
  Fully Specified Name: Medications on admission: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 35351
  Status (Raw): ACTIVE


8648-8   Hospital course NarrativeHospital course NarrativeHospital course: Find: Pt: ^Patient: Nar:  

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

TERM DEFINITION/DESCRIPTION(S)
  Hospital course describes the sequence of events from admission to discharge in a hospital facility.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

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

MEMBER OF THESE PANELS
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  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}: -:
  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}: -:
  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}: -:
  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   LP72747-6  Hospital course 
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)
 
  医院病程:发现:时间点:^患者:叙述型:医院病程: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)
 
  Séjour hospitalier:Observation:Temps ponctuel:^Patient:Narratif:Séjour hospitalier:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Decorso ospedaliero:Osservazione:Pt:^Paziente:Nar:Decorso ospedaliero:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Curso do hospital:Achado:Pt:^Paciente:Nar:Curso do hospital:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Госпитальный курс:Находка:ТчкВрм:^Пациент:Опис:Госпитальный курс:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  curso hospitalario:hallazgo:punto en el tiempo:^paciente:Narrativo:curso hospitalario:hallazgo:punto en el tiempo:^paciente:Narrativo:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:19 PM
  Long Common Name: Hospital course Narrative
  Shortname: Hospital course
  Fully Specified Name: Hospital course: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 66171
  Status (Raw): ACTIVE


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

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

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

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: 12/12/2018 9:55:19 PM
  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


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
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
  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: 12/12/2018 9:55:20 PM
  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


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 
  Override Display Name for Form:  Reason for visit and Chief complaint
  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: 12/12/2018 9:55:20 PM
  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


42349-1   Reason for referral (narrative)Reason for referral (narrative)Reason for referral: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Reason for referral  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Reason for referral
  Long Common Name:  Reason for referral (narrative)

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: ATTACH.CLINRPT/Attachment
  First Released in Version: 2.16
  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
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  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}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP74273-1  Reason for referral 
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)
 
  关于转诊的原因:发现:时间点:^患者:叙述型:关于转诊的原因:发现:时间点:^患者:叙述型:
  German (AUSTRIA)  (From: ELGA, Austria)
 
  Zuweisungsdiagnose
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Motivo per rinvio:Osservazione:Pt:^Paziente:Nar:Motivo per rinvio:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Motivo do encaminhamento:Achado:Pt:^Paciente:Nar:Motivo do encaminhamento:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Причина направления:Находка:ТчкВрм:^Пациент:Опис:Причина направления:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  ATTACH Findings Random
  ATTACH.CLINRPT Narrative Report
  Finding Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:20 PM
  Attachment Units Required: N
  Long Common Name: Reason for referral (narrative)
  Fully Specified Name: Reason for referral: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 35354
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Advance directives  Find  Pt  {Setting}  Doc  {Role}
  Override Display Name for Form:  Advanced directives
  Long Common Name:  Advance directives
  Shortname:  Advance directives

TERM DEFINITION/DESCRIPTION(S)
  Advance directives contains data defining the patient's direction of care and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. Advance directives contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.16
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Based on Clinical LOINC Committee review at the Feb. 2016 meeting, this term represents a document containing information on a patient's advance directives and any supporting documentation, such as a living will. The term was revised to fit the current LOINC Document Ontology model.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  71531-8   ESRD hospitalization panelESRD hospitalization panelHospitalization panel: -: Pt: ^Patient: -: ESRD
  72232-2   Continuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81214-9   Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

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

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:20 PM
  Attachment Units Required: N
  Long Common Name: Advance directives
  Shortname: Advance directives
  Fully Specified Name: Advance directives: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 2
  ID: 35353
  Status (Raw): ACTIVE


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

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

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

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

PARTS

Part Type    Part No.  Part Name   
Component   LP212514-6  Present illness 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  现有疾病:历史记录:时间点:^患者:叙述型:现有疾病:历史记录:时间点:^患者:叙述型:
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Anamnese der aktuellen Krankheit:Bef:Pkt:^Patient:Nar:BerichtetAnamnese der aktuellen Krankheit:Bef:Pkt:^Patient:Nar:Berichtet
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Malattia attuale:Hx:Pt:^Paziente:Nar:Malattia attuale:Hx:Pt:^Paziente:Nar:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:21 PM
  Long Common Name: History of Present illness Narrative
  Shortname: Hx of Pres illness
  Fully Specified Name: Present illness: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 211
  Status (Raw): ACTIVE


10158-4   History of Functional status NarrativeHistory of Functional status NarrativeFunctional status: Hx: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Functional status  Hx  Pt  ^Patient  Nar 
  Long Common Name:  History of Functional status Narrative
  Shortname:  Hx of Functional status

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0i
  Last Updated in Version: 2.56
  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.

MEMBER OF THESE PANELS
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72615-5  Functional status 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  功能状态:历史记录:时间点:^患者:叙述型:功能状态:历史记录:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Stato funzionale:Hx:Pt:^Paziente:Nar:Stato funzionale:Hx:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Функциональный статус:Hx:ТчкВрм:^Пациент:Опис:Функциональный статус:Hx:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes del estado funcional:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes del estado funcional: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: NAM

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:21 PM
  Long Common Name: History of Functional status Narrative
  Shortname: Hx of Functional status
  Fully Specified Name: Functional status: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 204
  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:  History of family member diseases
  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: 12/12/2018 9:55:21 PM
  Long Common Name: History of family member diseases Narrative
  Shortname: Family member diseases Hx
  Fully Specified Name: History of family member diseases: Hx: Pt: ^Family member: Nar:
     
  Component Word Count: 5
  ID: 203
  Status (Raw): ACTIVE


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

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

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

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: 12/12/2018 9:55:22 PM
  Attachment Units Required: N
  Long Common Name: Social history Narrative
  Shortname: Social Hx
  Fully Specified Name: Social history: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 21551
  Status (Raw): ACTIVE


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

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

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

OBSERVATION REQUIRED IN PANEL
Optional

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

MEMBER OF THESE PANELS
  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: -:
  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}: -:
  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}: -:
  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}: -:
  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: -:

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:22 PM
  Long Common Name: History of Immunization Narrative
  Shortname: Hx of Immunization
  Fully Specified Name: Immunization: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 1
  ID: 1553
  Status (Raw): ACTIVE


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

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

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

PARTS

Part Type    Part No.  Part Name   
Component   LP212523-7  Surgical procedures 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP100628-9  Surgical 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外科手术操作项目类:历史记录:时间点:^患者:叙述型:外科手术操作项目类:历史记录:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedure chirurgiche:Hx:Pt:^Paziente:Nar:Procedure chirurgiche:Hx:Pt:^Paziente:Nar:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de procedimientos quirúrgicos:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de procedimientos quirúrgicos:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:22 PM
  Long Common Name: History of Surgical procedures Narrative
  Shortname: Hx of Surg proc
  Fully Specified Name: Surgical procedures: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 215
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Hospitalizations+Outpatient visits  Hx  Pt  ^Patient  Nar 
  Override Display Name for Form:  History of hospitalizations+History of outpatient visits
  Long Common Name:  History of Hospitalizations+Outpatient visits Narrative
  Shortname:  Hx of Hospitalizations+OP visits

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

OBSERVATION REQUIRED IN PANEL
Optional

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

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  51896-9   Healthcare Associated Infection report - recommended CDA R2 sectionsHealthcare Associated Infection report - recommended CDA R2 sectionsHealthcare associated infection report - recommended CDA R2 sections: -: Pt: {Setting}: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  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}: -:
  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}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  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   LP72713-8  Hospitalizations+Outpatient visits 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 
Fragments for synonyms   LP100611-5  Outpatient 

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:23 PM
  Attachment Units Required: N
  Long Common Name: History of Hospitalizations+Outpatient visits Narrative
  Shortname: Hx of Hospitalizations+OP visits
  Fully Specified Name: Hospitalizations+Outpatient visits: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 39660
  Status (Raw): ACTIVE


11336-5   History of Hospitalization NarrativeHistory of Hospitalization NarrativeHospitalization: Hx: Pt: ^Patient: Nar:  

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

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: Changed Component from "History of hospitalizations" to "Hospitalization", Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  35089-2   History and physical panelHistory and physical panelHistory and physical panel: -: Pt: ^Patient: -:
  35090-0   Patient historyPatient historyPatient history: -: 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: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72712-0  Hospitalization   [History of hospitalization] 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  住院治疗史:历史记录:时间点:^患者:叙述型:住院治疗史: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.Hospitalisations:Hx:Temps ponctuel:^Patient:Narratif:Anamnèse.Hospitalisations:Hx:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Ospedalizzazioni:Hx:Pt:^Paziente:Nar:Ospedalizzazioni:Hx:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  История госпитализаций:Hx:ТчкВрм:^Пациент:Опис:История госпитализаций:Hx:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de hospitalizaciones:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de hospitalizaciones:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
  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.)
 
  hospitalizacion:Antecedente:Punto temporal:^paciente:Narrativo:hospitalizacion:Antecedente:Punto temporal:^paciente:Narrativo:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:23 PM
  Long Common Name: History of Hospitalization Narrative
  Shortname: Hx of Hospitalization
  Fully Specified Name: Hospitalization: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 1
  ID: 1516
  Status (Raw): ACTIVE


11346-4   History of Outpatient visits NarrativeHistory of Outpatient visits NarrativeOutpatient visits: Hx: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Outpatient visits  Hx  Pt  ^Patient  Nar 
  Override Display Name for Form:  History of outpatient visits
  Long Common Name:  History of Outpatient visits Narrative
  Shortname:  Hx of Outpt visits

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: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP212524-5  Outpatient visits 
Property   LP6817-3  Hx   [History] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP100611-5  Outpatient 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  门诊就诊类:历史记录:时间点:^患者:叙述型:门诊就诊类:历史记录:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Visite paziente esterno:Hx:Pt:^Paziente:Nar:Visite paziente esterno:Hx:Pt:^Paziente:Nar:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes de consultas ambulatorias:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes de consultas ambulatorias:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:23 PM
  Long Common Name: History of Outpatient visits Narrative
  Shortname: Hx of Outpt visits
  Fully Specified Name: Outpatient visits: Hx: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 1528
  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
  Override Display Name for Form:  Review of systems
  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: 12/12/2018 9:55:23 PM
  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


10184-0   Hospital discharge physical findings NarrativeHospital discharge physical findings NarrativeHospital discharge physical findings: Find: Pt: ^Patient: Nar:  

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

TERM DEFINITION/DESCRIPTION(S)
  Hospital discharge physical findings records a narrative description of the patient's physical findings.
 
 

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
  59271-7   Hospital discharge summary panelHospital discharge summary panelHospital discharge summary panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  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}: -:
  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}: -:
  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   LP72755-9  Hospital discharge physical findings 
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   LP100598-4  Discharge 
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)
 
  医院出院体格检查发现:发现:时间点:^患者:叙述型:医院出院体格检查发现: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)
 
  Examen physique de sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:Examen physique de sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Dimissione ospedaliera, osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:Dimissione ospedaliera, osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Госпитализация выбытие физикальные находки:Находка:ТчкВрм:^Пациент:Опис:Госпитализация выбытие физикальные находки:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  hallazgos físicos al momento del alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:hallazgos físicos al momento del alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:24 PM
  Long Common Name: Hospital discharge physical findings Narrative
  Shortname: Hospital discharge physical findings
  Fully Specified Name: Hospital discharge physical findings: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 4
  ID: 234
  Status (Raw): ACTIVE


22029-3   Physical exam NarrativePhysical exam NarrativePhysical exam.total: Find: Pt: ^Patient: Nar:  

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

TERM DEFINITION/DESCRIPTION(S)
  Text area for manual documentation from the history and physical examination about the history of the current tumor and the clinical description of the tumor... NAACCR Data Standards and Data Dictionary Version 11
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: TUMRRGT/Clinical
  First Released in Version: 1.0n
  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
  49083-9   North American Association of Central Cancer Registries, Inc (NAACCR, Inc) version 11 panelNorth American Association of Central Cancer Registries, Inc (NAACCR, Inc) version 11 panelNorth American Association of Central Cancer Registries, Inc (NAACCR, Inc) version 11 panel: -: Pt: ^Patient: -:
  59852-4   North American Association of Central Cancer Registries, Inc (NAACCR, Inc) version 12 panelNorth American Association of Central Cancer Registries, Inc (NAACCR, Inc) version 12 panelNorth American Association of Central Cancer Registries, Inc (NAACCR, Inc) version 12 panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP64627-0  Physical exam.total 
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   LP21089-5  Total 
Fragments for synonyms   LP100621-4  Physical exam 

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.汇总:发现:时间点:^患者:叙述型:体格检查.汇总: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)
 
  Examen physique.complet:Observation:Temps ponctuel:^Patient:Narratif:Examen physique.complet:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Esame obiettivo.totale:Osservazione:Pt:^Paziente:Nar:Esame obiettivo.totale:Osservazione:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Exame físico.total:Achado:Pt:^Paciente:Nar:Exame físico.total:Achado:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Физикальное исследование.общий:Находка:ТчкВрм:^Пациент:Опис:Физикальное исследование.общий:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  examen físico.total:hallazgo:punto en el tiempo:^paciente:Narrativo:examen físico.total:hallazgo:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Finding Point in time Totl
  Findings Random TUMOR REGISTRY(NAACCR)
  Narrative Report  
  PE Tot  

RELATED CODES
Code System Code Code Text Code Version
   NAACCR_ID   2520     

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:24 PM
  Long Common Name: Physical exam Narrative
  Shortname: Physical exam.total
  Fully Specified Name: Physical exam.total: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 13146
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Vital signs  Find  Pt  ^Patient  Nar  Observed
  Override Display Name for Form:  Vital signs, physical findings
  Long Common Name:  Vital signs
  Shortname:  Vital signs

TERM DEFINITION/DESCRIPTION(S)
  The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

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

MEMBER OF THESE PANELS
  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: -:
  57053-1   Nurse Emergency department NoteNurse Emergency department NoteNote: Find: Pt: Emergency department: Doc: Nurse
  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: -:
  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}: -:
  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}: -:
  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}: -:
  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   LP139953-6  Vital signs 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Method   LP6425-5  Observed 
Fragments for synonyms   LP75922-2  P' 

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:24 PM
  Long Common Name: Vital signs
  Shortname: Vital signs
  Fully Specified Name: Vital signs: Find: Pt: ^Patient: Nar: Observed
     
  Component Word Count: 2
  ID: 66230
  Status (Raw): ACTIVE


46242-4   Fetal Document Vital signs measurementsFetal Document Vital signs measurementsVital signs measurements: Find: Pt: ^Fetus: Doc:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Vital signs measurements  Find  Pt  ^Fetus  Doc 
  Override Display Name for Form:  Vital signs, fetus
  Long Common Name:  Fetal Document Vital signs measurements
  Shortname:  Fet Doc Vital signs measurements

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
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73695-6  Vital signs measurements 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6982-5  Fetus 
Scale   LP32888-7  Doc 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  生命体征测量结果:发现:时间点:^胎儿:文档型:生命体征测量结果:发现:时间点:^胎儿:文档型:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Mesure des signes vitaux:Observation:Temps ponctuel:^Foetus:Document:Mesure des signes vitaux:Observation:Temps ponctuel:^Foetus:Document:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Parametri vitali, misurazioni:Osservazione:Pt:^feto:Doc:Parametri vitali, misurazioni:Osservazione:Pt:^feto:Doc:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Avaliação de sinais vitais:Achado:Pt:^Feto:Doc:Avaliação de sinais vitais:Achado:Pt:^Feto:Doc:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Жизненно важные функции измерения:Находка:ТчкВрм:^Плод:Док:Жизненно важные функции измерения:Находка:ТчкВрм:^Плод:Док:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:25 PM
  Attachment Units Required: N
  Long Common Name: Fetal Document Vital signs measurements
  Shortname: Fet Doc Vital signs measurements
  Fully Specified Name: Vital signs measurements: Find: Pt: ^Fetus: Doc:
     
  Component Word Count: 3
  ID: 39662
  Status (Raw): ACTIVE


11493-4   Hospital discharge studies summary NarrativeHospital discharge studies summary NarrativeHospital discharge studies summary: Find: Pt: ^Patient: Nar:  

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

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: 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
  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: -:
  59271-7   Hospital discharge summary panelHospital discharge summary panelHospital discharge summary panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  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}: -:
  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}: -:
  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   LP72757-5  Hospital discharge studies summary 
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   LP100598-4  Discharge 
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)
 
  医院出院检查摘要:发现:时间点:^患者:叙述型:医院出院检查摘要: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)
 
  Résumé des études de sortie hospitalière:Observation:Temps ponctuel:^Patient:Narratif:Résumé des études de sortie hospitalière:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Dimissione ospedaliera, sintesi esami:Osservazione:Pt:^Paziente:Nar:Dimissione ospedaliera, sintesi esami:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Госпитализация выбытие исследования краткие сведения:Находка:ТчкВрм:^Пациент:Опис:Госпитализация выбытие исследования краткие сведения:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  resumen de los estudios para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:resumen de los estudios para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:25 PM
  Long Common Name: Hospital discharge studies summary Narrative
  Shortname: Hospital discharge studies summary
  Fully Specified Name: Hospital discharge studies summary: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 4
  ID: 903
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Relevant diagnostic tests &or laboratory data  Find  Pt  ^Patient  Nar 
  Override Display Name for Form:  Relevant diagnostic tests and/or laboratory data
  Long Common Name:  Relevant diagnostic tests/laboratory data Narrative
  Shortname:  Relevant Dx tests/lab data

OBSERVATION REQUIRED IN PANEL
Optional

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

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  55140-8   Vaccine Adverse Event Reporting System (VAERS) panelVaccine Adverse Event Reporting System (VAERS) panelVaccine Adverse Event Reporting System panel: -: Pt: ^Patient: -:
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57058-0   Maternal discharge summary noteMaternal discharge summary noteMaternal discharge summary note: Find: Pt: {Setting}: Doc: {Role}
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72232-2   Continuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74293-2   Oncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA set: -: Pt: {Setting}: -:
  81214-9   Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 9:55:25 PM
  Attachment Units Required: N
  Long Common Name: Relevant diagnostic tests/laboratory data Narrative
  Shortname: Relevant Dx tests/lab data
  Fully Specified Name: Relevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 6
  ID: 22892
  Status (Raw): ACTIVE


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
Optional

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: 12/12/2018 9:55:26 PM
  Long Common Name: Plan of care note
  Shortname: Plan of care note
  Fully Specified Name: Plan of care note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 4
  ID: 9693
  # of Panel Elements: 5
  Status (Raw): ACTIVE