Version 2.77

30525-0 Age

Observation Required in Panel

Optional

Fully-Specified Name

Component
Age
Property
Time
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Age
Display Name
Age
Consumer Name Alpha Get Info
Age

Basic Attributes

Class
MISC
Type
Laboratory
First Released
Version 2.04
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
1937

Member of these Panels

LOINC Long Common Name
58735-2 Alpha-1-Fetoprotein panel - Amniotic fluid
48802-3 Alpha-1-Fetoprotein panel - Serum or Plasma
95405-7 Assay related variables panel [PhenX]
93478-6 Busulfan area under the curve panel - Plasma
68991-9 Epidemiologically important information for public health reporting panel
49085-4 First and Second trimester integrated maternal screen panel
48798-3 First trimester maternal screen panel - Serum or Plasma
49086-2 First trimester maternal screen with nuchal translucency panel
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
96452-8 Hepatocellular carcinoma risk panel - Serum or Plasma
89543-3 Laboratory ask at order entry panel
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
78699-6 Liver fibrosis score panel - Serum or Plasma Calculated by FibroMeter
78698-8 Liver fibrosis score panel - Serum or Plasma Calculated by HepaScore
49087-0 Maternal screen clinical predictors panel
82259-3 Metabolic equivalent of task and Resting metabolic rate panel
89724-9 Minimum Data Set (MDS) for Public Health Emergency Operations Centers (EOC) [CDC Emergency Operations Centers]
87825-6 National Trauma Data Standard - version 2018 set
91393-9 Opioid risk tool panel
98133-2 Osteoporosis Index of Risk panel
98139-9 Osteoporosis Risk Assessment Instrument
98146-4 Osteoporosis Self-Assessment Tool
93149-3 PhenX - bone age protocol 220301
93340-8 PhenX - complete blood count protocol 220501
62863-6 PhenX domain - Infectious diseases and immunity
62755-4 PhenX domain - Neurology
62812-3 PhenX domain - Physical activity and physical fitness
62710-9 PhenX domain - Psychiatric
62611-9 PhenX domain - Respiratory
63009-5 PhenX domain - Social environments
82287-4 Physical activity panel
81959-9 Public health laboratory ask at order entry panel
89544-1 Pulmonary Embolism Rule-out Criteria panel PERC
89694-4 Pulmonary Embolism Severity Index panel [PESI]
89549-0 Revised Geneva Score panel
48799-1 Second trimester penta maternal screen panel - Serum or Plasma
48800-7 Second trimester quad maternal screen panel - Serum or Plasma
35086-8 Second trimester triple maternal screen panel - Serum or Plasma
60687-1 Test of Infant Motor Performance Version 5.1
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Alter:Zeit:Zeitpunkt:^Patient:Quantitativ:
es-AR Spanish (Argentina) edad:tiempo:punto en el tiempo:^paciente:cuantitativo:
es-ES Spanish (Spain) Edad:Tiempo:Punto temporal:^paciente:Qn:
Synonyms: Cuantitativo
es-MX Spanish (Mexico) Edad:Tiempo (por ejemplo, segundos):Punto temporal:^ Paciente:Cuantitativo:
et-EE Estonian (Estonia) Vanus:Aeg:Pt:^patsient:Qn:
Synonyms: Juhuslik Kvantitatiivne
fr-FR French (France) Âge:Temps:Ponctuel:Patient:Numérique:
fr-CA French (Canada) Âge:Durée:Temps ponctuel:^Patient:Quantitatif:
fr-BE French (Belgium) Âge:Durée:Temps ponctuel:^Patient:Quantitatif:
it-IT Italian (Italy) Età:Tempo:Pt:^Paziente:Qn:
Synonyms: Miscellanea paziente Punto nel tempo (episodio) Tempo (e.g. secondi)
nl-NL Dutch (Netherlands) leeftijd:tijd:moment:^patiënt:kwantitatief:
pt-BR Portuguese (Brazil) Idade:Tempo:Pt:^Paciente:Qn:
Synonyms: Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Возраст:Время:ТчкВрм:^Пациент:Колич:
Synonyms: Время (в т.ч. в секундах) Количественный Точка во времени;Момент
tr-TR Turkish (Turkey) Yaş:Süre:Zmlı:^Hasta:Kant:
zh-CN Chinese (China) 年龄:时间:时间点:^患者:定量型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 时间(如秒);时间(如秒数) 杂项;杂项类;杂项试验

Example Units

Unit Source
a Example UCUM Units

30972-4 Age at onset of adverse event

Observation Required in Panel

Optional

Fully-Specified Name

Component
Age at onset of adverse event
Property
Time
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Age at onset of AE

Basic Attributes

Class
VACCIN
Type
Clinical
First Released
Version 2.04
Last Updated
Version 2.40
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
68991-9 Epidemiologically important information for public health reporting panel
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) edad al comienzo del evento adverso:tiempo:punto en el tiempo:^paciente:cuantitativo:
es-MX Spanish (Mexico) Edad al inicio del evento adverso:Tiempo:Punto temporal:^ Paciente:Cuantitativo:
it-IT Italian (Italy) Età all'insorgenza di evento avverso:Tempo:Pt:^Paziente:Qn:
Synonyms: Età al momento della comparsa di evento avverso paziente Punto nel tempo (episodio) Tempo (e.g. secondi) Vaccinazioni
pt-BR Portuguese (Brazil) A idade do início do evento adverso:Tempo:Pt:^Paciente:Qn:
Synonyms: ; Age at onset of AE; Point in time; Random; Quantitative; QNT; Quant; Quan; VACCINE
ru-RU Russian (Russian Federation) Возраст на начало неблагоприятного события:Время:ТчкВрм:^Пациент:Колич:
Synonyms: Время (в т.ч. в секундах) Количественный Точка во времени;Момент
zh-CN Chinese (China) 不良事件起始年龄:时间:时间点:^患者:定量型:
Synonyms: 不良事件出现时的年龄;不良事件起始（开始、发病、发生、发作、开端、肇始）年龄 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 接种;接种记录;疫苗;疫苗接种 时刻;随机;随意;瞬间 时间(如秒);时间(如秒数)

Example Units

Unit Source
a Example UCUM Units

21612-7 Age - Reported

Term Description

For situations where birthdate is unknown; age is reported by third party
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Age
Property
Time
Time
Pt
System
^Patient
Scale
Qn
Method
Reported

Additional Names

Short Name
Age - Reported
Display Name
Age - Reported
Consumer Name Alpha Get Info
Age

Basic Attributes

Class
MISC
Type
Laboratory
First Released
Version 1.0m
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
90

Member of these Panels

LOINC Long Common Name
68991-9 Epidemiologically important information for public health reporting panel
69723-5 Patient Health Questionnaire (PHQ) [Reported]
62293-6 PhenX - current age protocol 010101
62263-9 PhenX domain - Nutrition and dietary supplements
62611-9 PhenX domain - Respiratory

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Alter:Zeit:Zeitpunkt:^Patient:Quantitativ:Berichtet
es-MX Spanish (Mexico) Edad:Tiempo (por ejemplo, segundos):Punto temporal:^ Paciente:Cuantitativo:Reportado
es-ES Spanish (Spain) Edad:Tiempo:Punto temporal:^paciente:Qn:Informado
Synonyms: Cuantitativo
es-AR Spanish (Argentina) edad:tiempo:punto en el tiempo:^paciente:cuantitativo:informado
fr-FR French (France) Âge:Temps:Ponctuel:Patient:Numérique:Résultat rapporté par un tiers
fr-BE French (Belgium) Âge:Durée:Temps ponctuel:^Patient:Quantitatif:Rapporté
fr-CA French (Canada) Âge:Durée:Temps ponctuel:^Patient:Quantitatif:Rapporté
it-IT Italian (Italy) Età:Tempo:Pt:^Paziente:Qn:Riportato
Synonyms: Miscellanea paziente Punto nel tempo (episodio) Tempo (e.g. secondi)
nl-NL Dutch (Netherlands) leeftijd:tijd:moment:^patiënt:kwantitatief:rapportage
pt-BR Portuguese (Brazil) Idade:Tempo:Pt:^Paciente:Qn:Relatado
Synonyms: Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Возраст:Время:ТчкВрм:^Пациент:Колич:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Время (в т.ч. в секундах) Количественный Точка во времени;Момент
tr-TR Turkish (Turkey) Yaş:Süre:Zmlı:^Hasta:Kant:Raporlanmış
zh-CN Chinese (China) 年龄:时间:时间点:^患者:定量型:报告法
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 时间(如秒);时间(如秒数) 杂项;杂项类;杂项试验

Example Units

Unit Source
a Example UCUM Units

54217-5 Public health notifiable condition

Term Description

Answer list based on the CDC Dwyer tables with the addition of Nationally Notifiable Disease Surveillance System (NNDSS) codes. This answer list is intended for general public health reporting, thus not a complete or definitive list.
Source: Regenstrief Institute

Observation Required in Panel

Optional

Fully-Specified Name

Component
Public health notifiable condition
Property
Prid
Time
Pt
System
XXX
Scale
Nom
Method

Additional Names

Short Name
PH notifiable condition

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.56
Change Reason
Changed answer list from "Normative" to "Preferred" to fit the current LOINC model.
Order vs. Observation
Observation

Preferred Answer List LL625-5

Answer Code Score Answer ID
AIDS 10560 LA10430-9
Amebiasis 11040 LA10431-7
Anthrax 10350 LA10432-5
Arbovirus infection no code LA10433-3
Babesiosis 12010 LA10434-1
Blastomyces infection of central nervous system no code LA10435-8
Blastomycosis no code LA10436-6
Botulism, other unspecified 10548 LA10437-4
Brucellosis 10020 LA10438-2
Campylobacteriosis 11020 LA10439-0
Cat scratch disease no code LA10440-8
Chancroid 10273 LA10441-6
Chlamydia trachomatis genital infection 10274 LA10442-4
Cholera (toxigenic Vibrio cholerae 01 or 0139) 10470 LA10443-2
Coccidioidomycosis 11900 LA10444-0
Colorado tick fever no code LA10445-7
Cryptococcosis no code LA10446-5
Cryptococcus infection of central nervous system no code LA10447-3
Cryptosporidiosis 11580 LA10448-1
Cyclosporiasis 11575 LA10449-9
Cysticercosis no code LA10450-7
Dengue Fever 10680 LA10451-5
Diphtheria 10040 LA10452-3
Ebola virus infection no code LA10453-1
Ehrlichiosis human, other or unspecified agent 11087 LA10454-9
Ehrlichiosis, human granulocytic (HGE) 11085 LA10455-6
Ehrlichiosis, human monocytic (HME) 11086 LA10456-4
Encephalitis/meningitis, California serogroup viral 10054 LA10457-2
Encephalitis/meningitis, eastern equine (EEE) 10053 LA10458-0
Encephalitis/meningitis, Powassan 10057 LA10459-8
Encephalitis/meningitis, St. Louis 10051 LA10460-6
Encephalitis/meningitis, Venezuelan equine (VEE) 10055 LA10461-4
Encephalitis/meningitis, West Nile 10056 LA10462-2
Encephalitis/meningitis, western equine (WEE) 10052 LA10463-0
Enterohemorrhagic Escherichia coli (EHEC) O157:H7 11560 LA10464-8
Enterohemorrhagic Escherichia coli (EHEC) shiga toxin+ (not serogrouped) 11564 LA10465-5
Giardiasis 11570 LA10466-3
Gonorrhea 10280 LA10467-1
Haemophilus influenzae, invasive disease 10590 LA10468-9
Hantavirus Pulmonary Syndrome 11590 LA10469-7
Heavy metal poisoning no code LA10470-5
Hepatitis A, acute 10110 LA10471-3
Hepatitis B, acute 10100 LA10472-1
Hepatitis C virus infection, past or present 10106 LA10473-9
Hepatitis C, acute 10101 LA10474-7
Hepatitis E, acute 10103 LA10475-4
Histoplasma infection of central nervous system no code LA10476-2
Histoplasmosis no code LA10477-0
Influenza (laboratory-confirmed) no code LA10478-8
Isosporiasis no code LA10479-6
Japanese encephalitis virus infection of central nervous system no code LA10480-4
Lassa fever no code LA10481-2
Lead poisoning 32010 LA10482-0
Legionellosis 10490 LA10483-8
Leptospirosis 10390 LA10484-6
Listeriosis 10640 LA10485-3
Louse-borne (epidemic) typhus no code LA10486-1
Lyme disease 11080 LA10487-9
Malaria 10130 LA10488-7
Measles (rubeola) 10140 LA10489-5
Meningococcal disease (Neisseria meningitidis) 10150 LA10490-3
Mumps 10180 LA10491-1
Neurosyphilis 10317 LA10492-9
Pertussis 10190 LA10493-7
Pesticide poisoning no code LA10494-5
Plague 10440 LA10495-2
Poliomyelitis, paralytic 10410 LA10496-0
Psittacosis (Ornithosis) 10450 LA10497-8
Q fever 10255 LA10498-6
Rabies, human 10460 LA10499-4
Relapsing fever no code LA10500-9
Rocky Mountain spotted fever 10250 LA10501-7
Rubella 10200 LA10502-5
Salmonellosis 11000 LA10503-3
SARS no code LA10504-1
Shigellosis 11010 LA10505-8
Streptococcal disease, invasive, Group A 11710 LA10506-6
Streptococcal disease, invasive, Group B 11715 LA10507-4
Streptococcus pneumoniae, invasive disease 11717 LA10508-2
Syphilis, primary 10311 LA10509-0
Tetanus 10210 LA10510-8
Toxoplasmosis 12020 LA10511-6
Trichinosis 10270 LA10512-4
Tuberculosis 10220 LA10513-2
Tularemia 10230 LA10514-0
Typhoid fever (caused by Salmonella typhi) 10240 LA10515-7
Typhus Fever, (endemic fleaborne, Murine) 10260 LA10516-5
Varicella (Chickenpox) 10030 LA10517-3
Vibrio spp., non-toxigenic, other or unspecified 11540 LA10518-1
West Nile Fever 10049 LA10519-9
Yellow fever 10660 LA10520-7
Yersiniosis 11565 LA10521-5

Member of these Panels

LOINC Long Common Name
68991-9 Epidemiologically important information for public health reporting panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Afección de notificación de salud pública:Tipo:Punto temporal:No especificado:Nominal:
fr-BE French (Belgium) Conditions de notification santé publique:Présence ou identité:Temps ponctuel:XXX:Nominal:
fr-CA French (Canada) Maladie à déclaration obligatoire:Présence ou identité:Temps ponctuel:XXX:Nominal:
it-IT Italian (Italy) Salute pubblica, condizione notificabile:Prid:Pt:XXX:Nom:
Synonyms: Clinico Condizione di Salute pubblica notificabile Presenza o Identità Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Declaração de condições de saúde pública:#N/A:Pt:XXX:Nom:
Synonyms: ; PH notifiAcle condition; Identity or presence; Point in time; Random; Misc; Miscellaneous; Unspecified; Other; Nominal
ru-RU Russian (Russian Federation) Общественное здоровье подлежащее регистрации состояние:ПрИд:ТчкВрм:XXX:Ном:
Synonyms: Номинальный;Именной Присутствие или Идентификация Точка во времени;Момент
zh-CN Chinese (China) 公共卫生法定上报疾病:存在与否或特征标识:时间点:XXX:名义型:
Synonyms: 不明的;其他;将在相应消息内其他部分之中加以详细说明;未作详细说明的;未作说明的;未做说明的标本;未加规定的;未加说明的标本;杂项 健康状况;疾病;情况;病情;状态;条件 公共卫生（公卫、公众健康、公共健康）法定上报疾病（健康状况、疫情）;公共卫生法定传染病;公共卫生须上报疾病;公共健康法定上报疾病;公众健康法定上报疾病;公共卫生法定申报疾病 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 存在;存在与否;特征标识;身份;身份标识 时刻;随机;随意;瞬间

11368-8 Illness or injury onset date and time

Observation Required in Panel

Optional

Fully-Specified Name

Component
Illness or injury onset date and time
Property
TmStp
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Illness or injury onset date and time

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Common Test Rank Get Info
273

Member of these Panels

LOINC Long Common Name
78000-7 Case notification panel [CDC.PHIN]
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
68991-9 Epidemiologically important information for public health reporting panel
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
89724-9 Minimum Data Set (MDS) for Public Health Emergency Operations Centers (EOC) [CDC Emergency Operations Centers]
62863-6 PhenX domain - Infectious diseases and immunity
81959-9 Public health laboratory ask at order entry panel
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) fecha/hora del inicio de la enfermedad/aparición de la lesión traumática:marca de tiempo:fecha y hora:punto en el tiempo:^paciente:cuantitativo:
es-MX Spanish (Mexico) Fecha y hora de aparición de la enfermedad o lesión:TmStp:Punto temporal:^ Paciente:Cuantitativo:
fr-BE French (Belgium) Condition médicale date et heure du début:Estampille temporelle:Temps ponctuel:^Patient:Quantitatif:
fr-CA French (Canada) Condition médicale date et heure du début:Estampille temporelle:Temps ponctuel:^Patient:Quantitatif:
it-IT Italian (Italy) Malattia o lesione, data e ora insorgenza:TmStp:Pt:^Paziente:Qn:
Synonyms: Anamnesi Data e ora comparsa malattia o lesione paziente Punto nel tempo (episodio) Time stamp (Data e Ora)
pt-BR Portuguese (Brazil) Data e tempo do inicio da doença ou lesão:TmStp:Pt:^Paciente:Qn:
Synonyms: Time stamp; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Заболевание или травма начало дата и время:TmStp:ТчкВрм:^Пациент:Колич:
Synonyms: Time Stamp (Дата и Время) Дата и время начала заболевания или травмы Количественный Точка во времени;Момент
zh-CN Chinese (China) 疾病或损伤起始日期与时间:时间戳:时间点:^患者:定量型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印时戳;时标;时间戳(日期与时间);时间标记;计时标记 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 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 日子;几号 日期与时间;日期及时间;日期时间 时刻;随机;随意;瞬间 时间(如秒);时间(如秒数) 疾病或损伤起始（开始、发病、发生、发作、开端、肇始）日期与时间;疾病或损伤发病日期与时间;疾病或损伤起病日期与时间;疾病或损伤发作日期与时间;疾病或损伤开始日期与时间;疾病或损伤初起日期与时间 病史与体格检查

11449-6 Pregnancy status - Reported

Term Description

Patient's pregnancy status (e.g., pregnant, not pregnant), as reported by the patient or the patient's proxy.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Pregnancy status
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
Reported

Additional Names

Short Name
Pregnancy status Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.73
Change Reason
10/2016: Added term description and example answer list; Updated Property to Find to align with similar terms
Order vs. Observation
Observation
Common Test Rank Get Info
4559

Example Answer List LL4129-4

Answer Code Score Answer ID
Pregnant LA15173-0
Not pregnant LA26683-5
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) LA4489-6

Member of these Panels

LOINC Long Common Name
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
68991-9 Epidemiologically important information for public health reporting panel
47245-6 HIV treatment form Document
89543-3 Laboratory ask at order entry panel

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Schwangerschafts-St.
es-AR Spanish (Argentina) estado de embarazo:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:informado
es-MX Spanish (Mexico) Estado de embarazo:Tipo:Punto temporal:^ Paciente:Nominal:Reported
it-IT Italian (Italy) Gravidanza, stato:Osservazione:Pt:^Paziente:Nom:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) Stato gravidico
nl-NL Dutch (Netherlands) zwangerschapsstatus:bevinding:moment:^patiënt:nominaal:rapportage
pt-BR Portuguese (Brazil) Estado de gravidez:Imp:Pt:^Paciente:Nom:Relatado
Synonyms: Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal; Gestation; Gravida; Gestations; Pregnancies
ru-RU Russian (Russian Federation) Беременность статус:Находка:ТчкВрм:^Пациент:Ном:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 妊娠状态:发现:时间点:^患者:名义型:报告法
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 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 怀孕;怀孕期;妊娠期 怀孕状态;妊娠状况;妊娠情况 时刻;随机;随意;瞬间 状况;情况 病史与体格检查