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
Cardiac surgery

Additional Names

Long Common Name
Cardiac surgery History and physical note
Short Name
Cardiac surgery 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
LG39111-6 Cardiac surgery|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38753-6 History and physical note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σημείωμα ιστορικού και φυσικής εξέτασης:Εύρεση:Pt:{Ρυθμίσεις}:Doc:Καρδιοχειρουργική
Synonyms: Εύρεση
it-IT Italian (Italy) Anamnesi e visita medica:Osservazione:Pt:{Setting}:Doc:Chirurgia cardiaca
Synonyms: Documentazione dell''ontologia Operazione chirurgica Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verslag voorgeschiedenis en lichamelijk onderzoek:bevinding:moment:{instelling}:document:cardiochirurgie
zh-CN Chinese (China) 病史与体格检查记录:发现:时间点:{环境}:文档型:心脏外科学
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 外科;外科手术;手术;手术室 心脏外科;心脏外;心外;心脏外科学手术;心脏外科手术;心脏手术;心脏外科学（心脏外科学手术、心脏外科、心脏外、心外、心脏外科手术、心脏手术） 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

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=101028-9