Version 2.80

Part Description

LP72701-3   History and physical note
History and physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. Source: HL7

Fully-Specified Name

Component
History and physical note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Surgical oncology

Additional Names

Long Common Name
Surgical oncology History and physical note
Short Name
Surg Onc H&P note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.74
Last Updated
Version 2.74 (ADD)
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38753-6 History and physical note|ANYRole|ANYSetting
LG39112-4 Surgical oncology|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σημείωμα ιστορικού και φυσικής εξέτασης:Εύρεση:Pt:{Ρυθμίσεις}:Doc:Χειρουργική ογκολογία
Synonyms: Εύρεση
it-IT Italian (Italy) Anamnesi e visita medica:Osservazione:Pt:{Setting}:Doc:Chirurgia oncologica
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio)
zh-CN Chinese (China) 病史与体格检查记录:发现:时间点:{环境}:文档型:外科肿瘤学
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 笔记;按语;注释;说明;票据;单据;证明书 肿瘤外科学;肿瘤外科 肿瘤学方法

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=101015-6