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}: -:  

PANEL HIERARCHY  (view this panel in the LForms viewer)

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  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}: -:    
       77599-9   Additional documentationAdditional documentationAdditional documentation: Find: Pt: {Setting}: Doc: {Role} R    
       77598-1   Externally defined clinical data elements DocumentExternally defined clinical data elements DocumentExternally defined clinical data elements: Find: Pt: {Setting}: Doc: {Role} R    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} R    
       77597-3   Orders placed DocumentOrders placed DocumentOrders placed: Find: Pt: {Setting}: Doc: {Role} R    
       18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role} R    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: R    
       77596-5   Transportation summary DocumentTransportation summary DocumentTransportation summary: Find: Pt: {Setting}: Doc: {Role} R    
       46241-6   Hospital admission diagnosis Narrative - ReportedHospital admission diagnosis Narrative - ReportedHospital admission Dx: Imp: Pt: ^Patient: Nar: Reported R    
       42346-7   Medications on admission (narrative)Medications on admission (narrative)Medications on admission: Find: Pt: ^Patient: Nar: R    
       48765-2   Allergies R    
       51848-0   Evaluation noteEvaluation noteEvaluation note: Find: Pt: {Setting}: Doc: {Role} R    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: R    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported R    
       11535-2   Hospital discharge Dx NarrativeHospital discharge Dx NarrativeHospital discharge Dx: Imp: Pt: ^Patient: Nar: R    
       10183-2   Hospital discharge medications NarrativeHospital discharge medications NarrativeHospital discharge medications: Find: Pt: ^Patient: Nar: R    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: R    
       10210-3   Physical findings of General status NarrativePhysical findings of General status NarrativePhysical findings: Find: Pt: General status: Nar: Observed R    
       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: R    
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: R    
       10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar: R    
       18841-7   Hospital consultations DocumentHospital consultations DocumentHospital consultations: Type: Pt: ^Patient: Doc: R    
       8648-8   Hospital course NarrativeHospital course NarrativeHospital course: Find: Pt: ^Patient: Nar: R    
       8653-8   Hospital Discharge instructionsHospital Discharge instructionsDischarge instructions: Find: Pt: Hospital: Doc: {Role} R    
       10184-0   Hospital discharge physical findings NarrativeHospital discharge physical findings NarrativeHospital discharge physical findings: Find: Pt: ^Patient: Nar: R    
       11493-4   Hospital discharge studies summary NarrativeHospital discharge studies summary NarrativeHospital discharge studies summary: Find: Pt: ^Patient: Nar: R    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: R    
       69730-0   InstructionsInstructionsInstructions: Find: Pt: {Setting}: Doc: {Role} R    
       11329-0   History general Narrative - ReportedHistory general Narrative - ReportedHistory general: Find: Pt: ^Patient: Nar: Reported R    
       46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role} R    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: R    
       10190-7   Mental status NarrativeMental status NarrativeMental status: Find: Pt: ^Patient: Nar: Observed R    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: R    
       48768-6   Payment sources DocumentPayment sources DocumentPayment sources: Find: Pt: ^Patient: Doc: R    
       29545-1   Physical findings NarrativePhysical findings NarrativePhysical findings: Find: Pt: ^Patient: Nar: Observed 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    
       29299-5   Reason for visit NarrativeReason for visit NarrativeReason for visit: Find: Pt: ^Patient: Nar: R    
       30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar: R    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported R    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed R    
 

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Enhanced discharge summary - recommended CDP Set 1 R1.1 sections  Pt  {Setting} 
  Long Common Name:  Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  Shortname:  Encd Discharge Sum CDP1 R1.1

TERM DEFINITION/DESCRIPTION(S)
  This panel contains the recommended sections for an enhanced discharge summary note based on the HL7 Clinical Documents for Payers - Set 1, Release 1.1 (US Realm).
 
 

BASIC ATTRIBUTES
  Class/Type: PANEL.DOC/Clinical
  Panel Type: Convenience group
  First Released in Version: 2.56
  Last Updated in Version: 2.58
  Status: Active

PARTS

Part Type    Part No.  Part Name   
Component   LP212485-9  Enhanced discharge summary - recommended CDP Set 1 R1.1 sections 
Property   LP6769-6 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP7747-1 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP21265-1 
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)
 
  增强型出院摘要 - 推荐 CDP 集合 1 R1.1 小节:-:时间点:{环境}:-:增强型出院摘要 - 推荐 CDP 集合 1 R1.1 小节:-:时间点:{环境}:-:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Sintesi dimissione arricchita- sezioni CDP Set 1 R1.1 raccomandate:-:Pt:{Setting}:-:Sintesi dimissione arricchita- sezioni CDP Set 1 R1.1 raccomandate:-:Pt:{Setting}:-:

RELATED NAMES
  Disch Panel Point in time
  Encd Discharge Sum CDP1 R1.1 PANEL.DOC Random
  i Panl  
  Pan Pnl  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:27 PM
  Long Common Name: Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
  Shortname: Encd Discharge Sum CDP1 R1.1
  Fully Specified Name: Enhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
     
  Component Word Count: 9
  ID: 85932
  # of Panel Elements: 43
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



77599-9   Additional documentationAdditional documentationAdditional documentation: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Additional documentation  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Additional documentation
  Shortname:  Additional documentation

TERM DEFINITION/DESCRIPTION(S)
  This document contains additional documentation captured by the provider related to care provided or planned for the patient that is not supported in any other section of the document. This term was created for, but not limited in use to, the Additional documentation section in the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.52
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  Status: Trial – caution, may change.
Change Reason: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  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}: -:
  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   LP192140-4  Additional documentation 
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   LP35025-3  Additional 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  附加文档记录:发现:时间点:{环境}:文档型:{角色}附加文档记录: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)
 
  Ulteriore documentazione:Osservazione:Pt:{Setting}:Doc:{Role}Ulteriore documentazione:Osservazione:Pt:{Setting}:Doc:{Role}

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:28 PM
  Long Common Name: Additional documentation
  Shortname: Additional documentation
  Fully Specified Name: Additional documentation: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 2
  ID: 80080
  Status (Raw): TRIAL


77598-1   Externally defined clinical data elements DocumentExternally defined clinical data elements DocumentExternally defined clinical data elements: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Externally defined clinical data elements  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Externally defined clinical data elements Document
  Shortname:  Externally defined CDEs Doc

TERM DEFINITION/DESCRIPTION(S)
  Externally defined clinical data elements section contains data that may be created through the interaction of the provider with templates (internal to the EHR or externally defined) that store XML tagged name-value pairs or more complex XML tagged information/content models and a reference to the externally defined information/content model, value set or clinical vocabulary. The referenced content model, value set or clinical vocabulary shall be pointed to by a URI in the Externally Defined CDA organizer and the specific XML tagged data shall be included in the Externally Defined CDE template. This term was created for, but not limited in use to, the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.52
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  Status: Trial – caution, may change.
Change Reason: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  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}: -:
  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   LP191787-3  Externally defined clinical data elements 
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] 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外部定义型临床数据元:发现:时间点:{环境}:文档型:{角色}外部定义型临床数据元: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)
 
  Dati clinici definiti esternamente:Osservazione:Pt:{Setting}:Doc:{Role}Dati clinici definiti esternamente:Osservazione:Pt:{Setting}:Doc:{Role}

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:28 PM
  Long Common Name: Externally defined clinical data elements Document
  Shortname: Externally defined CDEs Doc
  Fully Specified Name: Externally defined clinical data elements: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 5
  ID: 80079
  Status (Raw): TRIAL


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

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

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

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.19
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Based on Clinical LOINC Committee approval on 2/17/2012, "note" was added to the Component as the Kind of Document.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

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

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

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:28 PM
  Attachment Units Required: N
  Long Common Name: Functional status assessment note
  Shortname: Functional status note
  Fully Specified Name: Functional status assessment note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 4
  ID: 40938
  Status (Raw): ACTIVE


77597-3   Orders placed DocumentOrders placed DocumentOrders placed: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Orders placed  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Orders placed Document
  Shortname:  Orders placed Doc

TERM DEFINITION/DESCRIPTION(S)
  Orders placed section contains active and completed (not planned) orders for observations, interventions, encounters, services, and procedures for the patient. Order information is used to validate that clinical activities performed by other providers and suppliers authorized by the responsible provider. The details of orders are provided but not the acts involved in the processing and fulfillment of the order. In general, planned order activity is included under the plan of treatment section (also known as "plan of care") [LOINC: 18776-5] . This term was created for, but not limited in use to, the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.52
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  Status: Trial – caution, may change.
Change Reason: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  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}: -:
  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   LP191789-9  Orders placed 
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] 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  已下达的医嘱:发现:时间点:{环境}:文档型:{角色}已下达的医嘱: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)
 
  Oridini fatti:Osservazione:Pt:{Setting}:Doc:{Role}Oridini fatti:Osservazione:Pt:{Setting}:Doc:{Role}

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:28 PM
  Long Common Name: Orders placed Document
  Shortname: Orders placed Doc
  Fully Specified Name: Orders placed: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 2
  ID: 80078
  Status (Raw): TRIAL


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

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

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

OBSERVATION REQUIRED IN PANEL
Required

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

ASSOCIATED OBSERVATIONS

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

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

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72232-2   Continuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74293-2   Oncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA set: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81214-9   Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

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

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:29 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


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

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

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

OBSERVATION REQUIRED IN PANEL
Required

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 6:06:29 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


77596-5   Transportation summary DocumentTransportation summary DocumentTransportation summary: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Transportation summary  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Transportation summary Document
  Shortname:  Transport summary Doc

TERM DEFINITION/DESCRIPTION(S)
  A transportation summary includes the method (such as emergency transport) that was used to bring the patient to the location for the current encounter. This information is often provided as a summary by the entity that provides the transportation service. This term was created for, but not limited in use to, the Transportation section in the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.52
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  Status: Trial – caution, may change.
Change Reason: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  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}: -:
  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   LP192137-0  Transportation summary 
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] 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  运输摘要:发现:时间点:{环境}:文档型:{角色}运输摘要: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)
 
  Transporto, riassunto:Osservazione:Pt:{Setting}:Doc:{Role}Transporto, riassunto:Osservazione:Pt:{Setting}:Doc:{Role}

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:29 PM
  Long Common Name: Transportation summary Document
  Shortname: Transport summary Doc
  Fully Specified Name: Transportation summary: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 2
  ID: 80077
  Status (Raw): TRIAL


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
Required

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 6:06:30 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


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
Required

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 6:06:30 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


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

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

TERM DEFINITION/DESCRIPTION(S)
  Contains a list and description of any allergies or adverse reactions pertinent to current or past medical history. At a minimum this section should contain currently active and any relevant historical allergies and adverse reactions.
 
 

OBSERVATION REQUIRED IN PANEL
Required

TYPE OF ENTRY
Question

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.21
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: Edited Component part from "Allergies, adverse reactions, alerts" to "Allergies &or adverse reactions." We removed the word "alerts" because it was potentially confusing by implying that it may contain other kinds of warnings (as a arbitrary example: public health disease outbreak notifications) when in fact it was always intended to be the typical "allergies" section.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  57057-2   Labor and delivery summary noteLabor and delivery summary noteLabor and delivery summary note: Find: Pt: {Setting}: Doc: {Role}
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  57083-8   Labor and Delivery record panelLabor and Delivery record panelLabor and Delivery record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72232-2   Continuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74293-2   Oncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA set: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81214-9   Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  82315-3   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sectionsLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 sectionsLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:
  84429-0   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 set: -: Pt: {Setting}: -:

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:30 PM
  Attachment Units Required: N
  Long Common Name: Allergies and adverse reactions Document
  Shortname: Allergies &or adverse reactions Doc
  Fully Specified Name: Allergies &or adverse reactions: Find: Pt: ^Patient: Doc:
     
  Component Word Count: 4
  ID: 42482
  Status (Raw): ACTIVE


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

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

TERM DEFINITION/DESCRIPTION(S)
  An evaluation (also called asessment, impression or diagnoses) note represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block.
 
 

OBSERVATION REQUIRED IN PANEL
Required

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

MEMBER OF THESE PANELS
  57053-1   Nurse Emergency department NoteNurse Emergency department NoteNote: Find: Pt: Emergency department: Doc: Nurse
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

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

PARTS

Part Type    Part No.  Part Name   
Component   LP74507-2  Evaluation note 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP21013-5  Evaluation 
Fragments for synonyms   LP183649-5  note 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  评价记录:发现:时间点:{环境}:文档型:{角色}评价记录:发现:时间点:{环境}:文档型:{角色}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Valutazione, nota:Osservazione:Pt:{Setting}:Doc:{Role}Valutazione, nota:Osservazione:Pt:{Setting}:Doc:{Role}

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:30 PM
  Attachment Units Required: N
  Long Common Name: Evaluation note
  Shortname: Eval note
  Fully Specified Name: Evaluation note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 2
  ID: 45853
  Status (Raw): ACTIVE


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

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

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

OBSERVATION REQUIRED IN PANEL
Required

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 6:06:31 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


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

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

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

OBSERVATION REQUIRED IN PANEL
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: 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 6:06:31 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


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 
  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
Required

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 6:06:31 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


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 
  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
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: 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 6:06:32 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


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
History of family member diseases  Hx  Pt  ^Family member  Nar 
  Long Common Name:  History of family member diseases Narrative
  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
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: 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 6:06:32 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


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

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

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

OBSERVATION REQUIRED IN PANEL
Required

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

MEMBER OF THESE PANELS
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  55169-7   Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73100-7  Physical findings 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP29998-9  General status 
Scale   LP7749-7  Nar 
Method   LP6425-5  Observed 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  体格检查发现:发现:时间点:一般状态:叙述型:观察法体格检查发现:发现:时间点:一般状态:叙述型:观察法
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Osservazioni fisiche:Osservazione:Pt:Stato generale:Nar:OsservatoOsservazioni fisiche:Osservazione:Pt:Stato generale:Nar:Osservato
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Achados físicos:Achado:Pt:Estado geral:Nar:ObservadoAchados físicos:Achado:Pt:Estado geral:Nar:Observado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Физикальные находки:Находка:ТчкВрм:Общий статус:Опис:НаблюдённыйФизикальные находки:Находка:ТчкВрм:Общий статус:Опис:Наблюдённый
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  hallazgos físicos:hallazgo:punto en el tiempo:estado general:Narrativo:observadohallazgos físicos:hallazgo:punto en el tiempo:estado general:Narrativo:observado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:32 PM
  Long Common Name: Physical findings of General status Narrative
  Shortname: Phys find General status
  Fully Specified Name: Physical findings: Find: Pt: General status: Nar: Observed
     
  Component Word Count: 2
  ID: 262
  Status (Raw): ACTIVE


61146-7   Goals NarrativeGoals NarrativeGoals: Find: Pt: ^Patient: Nar:  

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

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.34
  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
  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}: -:
  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}: -:
  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   LP102364-9  Goals 
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)
 
  目标:发现:时间点:^患者:叙述型:目标:发现:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Obiettivi:Osservazione:Pt:^Paziente:Nar:Obiettivi:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Цели:Находка:ТчкВрм:^Пациент:Опис:Цели:Находка:ТчкВрм:^Пациент:Опис:
  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.)
 
  Objetivos:Hallazgo:Punto temporal:^paciente:Narrativo:Objetivos:Hallazgo:Punto temporal:^paciente:Narrativo:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:32 PM
  Attachment Units Required: N
  Long Common Name: Goals Narrative
  Shortname: Goals
  Fully Specified Name: Goals: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 1
  ID: 56214
  Status (Raw): ACTIVE


75310-3   Health concerns DocumentHealth concerns DocumentHealth concerns: Find: Pt: ^Patient: Doc:  

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

TERM DEFINITION/DESCRIPTION(S)
  A section that contains data describing an interest or worry about a health state or process that could possibly require attention, intervention, or management.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: HL7.CCDA/Clinical
  First Released in Version: 2.50
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  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
  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}: -:
  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}: -:
  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   LP185390-4  Health concerns 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP32888-7  Doc 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  健康关注事项:发现:时间点:^患者:文档型:健康关注事项:发现:时间点:^患者:文档型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Preoccupazioni per la salute:Osservazione:Pt:^Paziente:Doc:Preoccupazioni per la salute:Osservazione:Pt:^Paziente:Doc:

RELATED NAMES
  Document health concern Random
  Finding HL7CCDA  
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:33 PM
  Long Common Name: Health concerns Document
  Shortname: Health concern Doc
  Fully Specified Name: Health concerns: Find: Pt: ^Patient: Doc:
     
  Component Word Count: 2
  ID: 76988
  Status (Raw): ACTIVE


11383-7   Patient problem outcome NarrativePatient problem outcome NarrativePatient problem outcome: Find: Pt: ^Patient: Nar:  

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

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 1.0j-a
  Last Updated in Version: 2.40
  Status: Active

MEMBER OF THESE PANELS
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  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}: -:
  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}: -:
  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   LP73077-7  Patient problem outcome 
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)
 
  患者问题结局:发现:时间点:^患者:叙述型:患者问题结局: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)
 
  Problèmes avenir patient:Observation:Temps ponctuel:^Patient:Narratif:Problèmes avenir patient:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Paziente, esito problema:Osservazione:Pt:^Paziente:Nar:Paziente, esito problema:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Пациент проблема исход:Находка:ТчкВрм:^Пациент:Опис:Пациент проблема исход:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  evolución del problema del paciente:hallazgo:punto en el tiempo:^paciente:Narrativo:evolución del problema del paciente: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 6:06:33 PM
  Long Common Name: Patient problem outcome Narrative
  Shortname: Patient problem outcome
  Fully Specified Name: Patient problem outcome: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 1568
  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
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: 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 6:06:33 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


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 
  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
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: -:
  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 6:06:33 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


18841-7   Hospital consultations DocumentHospital consultations DocumentHospital consultations: Type: Pt: ^Patient: Doc:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Hospital consultations  Type  Pt  ^Patient  Doc 
  Long Common Name:  Hospital consultations Document

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: ATTACH.CLINRPT/Attachment
  First Released in Version: 1.0l
  Last Updated in Version: 2.40
  Order vs. Obs.: Both
  Status: Active

MEMBER OF THESE PANELS
  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}: -:
  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}: -:
  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   LP72746-8  Hospital consultations 
Property   LP6886-8  Type 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP32888-7  Doc 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  医院会诊:类型:时间点:^患者:文档型:医院会诊:类型:时间点:^患者:文档型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Consulti ospedalieri:Tipo:Pt:^Paziente:Doc:Consulti ospedalieri:Tipo:Pt:^Paziente:Doc:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Consultas hospitalares:Tipo:Pt:^Paciente:Doc:Consultas hospitalares:Tipo:Pt:^Paciente:Doc:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Госпитальные консультации:Тип:ТчкВрм:^Пациент:Док:Госпитальные консультации:Тип:ТчкВрм:^Пациент:Док:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  interconsultas hospitalarias:tipo:punto en el tiempo:^paciente:Documento:interconsultas hospitalarias:tipo:punto en el tiempo:^paciente:Documento:

RELATED NAMES
  ATTACH Hosp Typ
  ATTACH.CLINRPT Point in time  
  Document Random  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:34 PM
  Long Common Name: Hospital consultations Document
  Fully Specified Name: Hospital consultations: Type: Pt: ^Patient: Doc:
     
  Component Word Count: 2
  ID: 9750
  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 
  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
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: 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 6:06:34 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


8653-8   Hospital Discharge instructionsHospital Discharge instructionsDischarge instructions: Find: Pt: Hospital: Doc: {Role}  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Discharge instructions  Find  Pt  Hospital  Doc  {Role}
  Long Common Name:  Hospital Discharge instructions
  Shortname:  Hosp Discharge instruct

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 1.0h(3)
  Last Updated in Version: 2.54
  Status: Active.
Change Reason: Updated term to represent the current LOINC Document Ontology model.; 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.

MEMBER OF THESE PANELS
  59271-7   Hospital discharge summary panelHospital discharge summary panelHospital discharge 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}: -:

MEMBER OF THESE EQUIVALENCE GROUPS
  LG38843-5  Discharge instructions|ANYRole|ANYSetting
  LG41829-9  Hospital|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP101193-3  Discharge instructions 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP76009-7  Hospital 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP100598-4  Discharge 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  出院指导:发现:时间点:医院:文档型:{角色}出院指导:发现:时间点:医院:文档型:{角色}
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Istruzioni di dimissione:Osservazione:Pt:Ospedale:Doc:{Role}Istruzioni di dimissione:Osservazione:Pt:Ospedale:Doc:{Role}
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Instruções de alta hospitalar:Txt:Pt:^Paciente:Nar:Instruções de alta hospitalar:Txt:Pt:^Paciente:Nar:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  instrucciones para el alta del hospital:texto:punto en el tiempo:^paciente:Narrativo:instrucciones para el alta del hospital:texto:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Disch Finding Inpatient
  DOC.ONT Findings Point in time
  Document Hosp Random

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:34 PM
  Long Common Name: Hospital Discharge instructions
  Shortname: Hosp Discharge instruct
  Fully Specified Name: Discharge instructions: Find: Pt: Hospital: Doc: {Role}
     
  Component Word Count: 2
  ID: 66177
  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 
  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
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: 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 6:06:34 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


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 
  Long Common Name:  Hospital discharge studies summary Narrative
  Shortname:  Hospital discharge studies summary

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
  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 6:06:35 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


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Immunization  Hx  Pt  ^Patient  Nar 
  Long Common Name:  History of Immunization Narrative
  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
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: 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 6:06:35 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


69730-0   InstructionsInstructionsInstructions: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Instructions  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Instructions
  Shortname:  Instructions

TERM DEFINITION/DESCRIPTION(S)
  The Instructions section records instructions given to a patient. Examples of what it might contain include: instructions about not resuming normal activities, potential complications, use of medications, follow-up with healthcare providers, etc.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.38
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  Status: Active.
Change Reason: Updated System, Scale and Property to harmonize with the currently LOINC Document Ontology model.; 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

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  80582-0   LOINC Document Ontology associated observations panelLOINC Document Ontology associated observations panelLOINC Document Ontology associated observations panel: -: Pt: Clinical document: -:    
       74478-9   Clinical document Type of service from LOINC Document OntologyClinical document Type of service from LOINC Document OntologyType of service: Find: Pt: Clinical document: Nom: LOINC Document Ontology    
       74477-1   Clinical document Kind of document from LOINC Document OntologyClinical document Kind of document from LOINC Document OntologyKind of document: Find: Pt: Clinical document: Nom: LOINC Document Ontology    
       74476-3   Clinical document Setting from LOINC Document OntologyClinical document Setting from LOINC Document OntologySetting: Find: Pt: Clinical document: Nom: LOINC Document Ontology    
       74480-5   Clinical document Subject matter domain from LOINC Document OntologyClinical document Subject matter domain from LOINC Document OntologySubject matter domain: Find: Pt: Clinical document: Nom: LOINC Document Ontology    
       74479-7   Clinical document Role from LOINC Document OntologyClinical document Role from LOINC Document OntologyRole: Find: Pt: Clinical document: Nom: LOINC Document Ontology    
 

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

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

PARTS

Part Type    Part No.  Part Name   
Component   LP140599-4  Instructions 
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] 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  说明:发现:时间点:{环境}:文档型:{角色}说明: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)
 
  Istruzioni:Osservazione:Pt:{Setting}:Doc:{Role}Istruzioni:Osservazione:Pt:{Setting}:Doc:{Role}

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:35 PM
  Attachment Units Required: N
  Long Common Name: Instructions
  Shortname: Instructions
  Fully Specified Name: Instructions: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 1
  ID: 69048
  # of Panel Elements: 6
  Status (Raw): ACTIVE


11329-0   History general Narrative - ReportedHistory general Narrative - ReportedHistory general: Find: Pt: ^Patient: Nar: Reported  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
History general  Find  Pt  ^Patient  Nar  Reported
  Long Common Name:  History general Narrative - Reported
  Shortname:  Hx general Reported

TERM DEFINITION/DESCRIPTION(S)
  History general describes all aspects of medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. It may also be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Past Medical History and Social History.
 
 

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
  72230-6   Diagnostic imaging report - recommended C-CDA R1.1 sectionsDiagnostic imaging report - recommended C-CDA R1.1 sectionsDiagnostic imaging report - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  81220-6   Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sectionsDiagnostic imaging report - recommended C-CDA R2.0 and R2.1 sectionsDiagnostic imaging report - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  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}: -:
  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}: -:
  87416-4   Diagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP64608-0  History general 
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   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)
 
  一般病史:发现:时间点:^患者:叙述型:报告法一般病史: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)
 
  Histoire générale:Observation:Temps ponctuel:^Patient:Narratif:RapportéHistoire générale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Storia generale:Osservazione:Pt:^Paziente:Nar:RiportatoStoria generale:Osservazione:Pt:^Paziente:Nar:Riportato
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  История общая:Находка:ТчкВрм:^Пациент:Опис:СообщенныйИстория общая:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  antecedentes generales:hallazgo:punto en el tiempo:^paciente:Narrativo:informadoantecedentes generales:hallazgo:punto en el tiempo:^paciente:Narrativo:informado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:36 PM
  Long Common Name: History general Narrative - Reported
  Shortname: Hx general Reported
  Fully Specified Name: History general: Find: Pt: ^Patient: Nar: Reported
     
  Component Word Count: 2
  ID: 1509
  Status (Raw): ACTIVE


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

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

TERM DEFINITION/DESCRIPTION(S)
  History of medical device (medical equipment) use defines a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history. This term is also used to itemize any pertinent current or historical durable medical equipment (DME) used to help maintain the patient's health status. All pertinent equipment relevant to the diagnosis, care, and treatment of a patient should be included.
 
 

OBSERVATION REQUIRED IN PANEL
Required

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

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

MEMBER OF THESE PANELS
  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: -:
  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}: -:
  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}: -:
  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   LP74100-6  History of medical device use 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP91302-7  History 
Fragments for synonyms   LP100603-2  History of 

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:36 PM
  Attachment Units Required: N
  Long Common Name: History of medical device use
  Fully Specified Name: History of medical device use: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 5
  ID: 39686
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Medication use  Hx  Pt  ^Patient  Nar 
  Long Common Name:  History of Medication use Narrative
  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
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
  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 6:06:36 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


10190-7   Mental status NarrativeMental status NarrativeMental status: Find: Pt: ^Patient: Nar: Observed  

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

TERM DEFINITION/DESCRIPTION(S)
  Observations and evaluations related to a patient's psychological and mental competency and deficits including, but not limited to any of the following types of information: appearance, attitude, behavior/psychomotor, mood and affect, speech and language, thought process, thought content, perception, cognition, and insight and judgment.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 1.0i
  Last Updated in Version: 2.58
  Status: Active

MEMBER OF THESE PANELS
  55168-9   Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1Data Elements for Emergency Department Systems (DEEDS) Release 1.1: -: Pt: ^Patient: -:
  55169-7   Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0Data Elements for Emergency Department Systems (DEEDS) Release 1.0: -: Pt: ^Patient: -:
  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}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72938-1  Mental status 
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)
 
  心理状况:发现:时间点:^患者:叙述型:观察法心理状况: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)
 
  Status mental:Observation:Temps ponctuel:^Patient:Narratif:ObservéStatus mental:Observation:Temps ponctuel:^Patient:Narratif:Observé
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Stato mentale:Osservazione:Pt:^Paziente:Nar:OsservatoStato mentale:Osservazione:Pt:^Paziente:Nar:Osservato
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Психический статус:Находка:ТчкВрм:^Пациент:Опис:НаблюдённыйПсихический статус:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  estado mental:hallazgo:punto en el tiempo:^paciente:Narrativo:observadoestado mental:hallazgo:punto en el tiempo:^paciente: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 6:06:37 PM
  Long Common Name: Mental status Narrative
  Shortname: Mental status
  Fully Specified Name: Mental status: Find: Pt: ^Patient: Nar: Observed
     
  Component Word Count: 2
  ID: 240
  Status (Raw): ACTIVE


61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Diet and nutrition  Find  Pt  ^Patient  Nar 
  Long Common Name:  Diet and nutrition Narrative
  Shortname:  Diet+nutrition

TERM DEFINITION/DESCRIPTION(S)
  This section houses diet information such as special diets, restrictions, NPO, liquids only, etc..
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: H&P.HX/Clinical
  First Released in Version: 2.34
  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
  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   LP102362-3  Diet and nutrition 
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)
 
  膳食与营养:发现:时间点:^患者:叙述型:膳食与营养:发现:时间点:^患者:叙述型:
  French (FRANCE)  (From: ASIP Santé (Agence des systèmes d'information partagés de santé))
 
  Régime et alimentation:Recherche:Ponctuel:Patient:Commentaire:nullRégime et alimentation:Recherche:Ponctuel:Patient:Commentaire:nullRégime et alimentation [Recherche] Patient ; Commentaire
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Dieta e nutrizione:Osservazione:Pt:^Paziente:Nar:Dieta e nutrizione:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Диета и питание:Находка:ТчкВрм:^Пациент:Опис:Диета и питание:Находка:ТчкВрм:^Пациент:Опис:

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:37 PM
  Attachment Units Required: N
  Long Common Name: Diet and nutrition Narrative
  Shortname: Diet+nutrition
  Fully Specified Name: Diet and nutrition: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 56212
  Status (Raw): ACTIVE


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

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

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

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

OBSERVATION REQUIRED IN PANEL
Required

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

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

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:37 PM
  Attachment Units Required: N
  Long Common Name: Payment sources Document
  Shortname: Payment sources Doc
  Fully Specified Name: Payment sources: Find: Pt: ^Patient: Doc:
     
  Component Word Count: 2
  ID: 42485
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Physical findings  Find  Pt  ^Patient  Nar  Observed
  Long Common Name:  Physical findings Narrative
  Shortname:  Phys find

OBSERVATION REQUIRED IN PANEL
Required

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

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

PARTS

Part Type    Part No.  Part Name   
Component   LP73100-7  Physical findings 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Method   LP6425-5  Observed 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  体格检查发现:发现:时间点:^患者:叙述型:观察法体格检查发现:发现:时间点:^患者:叙述型:观察法
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Examen physique:Observation:Temps ponctuel:^Patient:Narratif:ObservéExamen physique:Observation:Temps ponctuel:^Patient:Narratif:Observé
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:OsservatoOsservazioni fisiche:Osservazione:Pt:^Paziente:Nar:Osservato
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Achados físicos:Achado:Pt:^Paciente:Nar:ObservadoAchados físicos:Achado:Pt:^Paciente:Nar:Observado
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Физикальные находки:Находка:ТчкВрм:^Пациент:Опис:НаблюдённыйФизикальные находки:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  hallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observadohallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observado

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:37 PM
  Attachment Units Required: N
  Long Common Name: Physical findings Narrative
  Shortname: Phys find
  Fully Specified Name: Physical findings: Find: Pt: ^Patient: Nar: Observed
     
  Component Word Count: 2
  ID: 21324
  Status (Raw): ACTIVE


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

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Problem list  Find  Pt  ^Patient  Nom  Reported
  Long Common Name:  Problem list - Reported
  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 6:06:38 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


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

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

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

OBSERVATION REQUIRED IN PANEL
Required

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

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  57053-1   Nurse Emergency department NoteNurse Emergency department NoteNote: Find: Pt: Emergency department: Doc: Nurse
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72232-2   Continuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74293-2   Oncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA set: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81214-9   Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  81898-9   Composite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE setComposite triage and nursing note - recommended IHE set: -: Pt: ^Patient: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

PARTS

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

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

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

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 6:06:38 PM
  Attachment Units Required: N
  Long Common Name: History of Procedures Document
  Shortname: Procedures Hx Doc
  Fully Specified Name: History of procedures: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 3
  ID: 41048
  Status (Raw): ACTIVE


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 
  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
Required

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 6:06:38 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


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

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

OBSERVATION REQUIRED IN PANEL
Required

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 6:06:38 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


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

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

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

OBSERVATION REQUIRED IN PANEL
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: 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