Version 2.78

Term Description

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.
Source: Regenstrief LOINC

Fully-Specified Name

Component
History general
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Reported

Additional Names

Short Name
Hx general Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Common Test Rank Get Info
3158

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) antecedentes generales:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Historia general:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Histoire générale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
Synonyms: Anamn?se
it-IT Italian (Italy) Storia generale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) voorgeschiedenis algemeen:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) История общая:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Общий анамнез Описательный Точка во времени;Момент
zh-CN Chinese (China) 一般病史:发现:时间点:^患者:叙述型:报告法
Synonyms: 一般史;一般历史;普通历史;普通史;普通病史 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 时刻;随机;随意;瞬间 病史与体格检查

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