Version 2.78

61146-7 Goals Narrative

Observation Required in Panel

Required

Fully-Specified Name

Component
Goals
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Goals

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.34
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
6503

Member of these Panels

LOINC Long Common Name
81215-6 Care plan - recommended C-CDA R2.0 and R2.1 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
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Metas:Tipo:Punto temporal:^ Paciente:Narrativo:
es-ES Spanish (Spain) Objetivos:Hallazgo:Punto temporal:^paciente:Narrativo:
it-IT Italian (Italy) Obiettivi:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) doelen:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Цели:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 目标:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 目的;目标类

75310-3 Health concerns Document

Term Description

A section that contains data describing an interest or worry about a health state or process that could possibly require attention, intervention, or management.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Health concerns
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Health concern Doc

Basic Attributes

Class
HL7.CCDA
Type
Clinical
First Released
Version 2.50
Last Updated
Version 2.63
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
81215-6 Care plan - recommended C-CDA R2.0 and R2.1 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
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Preocupaciones de salud:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Preoccupazioni per la salute:Osservazione:Pt:^Paziente:Doc:
Synonyms: HL7 Consolidated Clinical Document Architecture Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) aandachtspunt betreffende gezondheid:bevinding:moment:^patiënt:document:
zh-CN Chinese (China) 健康关注事项:发现:时间点:^患者:文档型:
Synonyms: HL7.统一临床文档架构;HL7 统一临床文档架构;HL7 联合临床文档架构;HL7 综合临床文档架构;HL7 Consolidated Clinical Document Architecture;CCDA 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 健康（卫生、身体健康）关注事项（关切事项） 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 时刻;随机;随意;瞬间

11383-7 Patient problem outcome Narrative

Observation Required in Panel

Optional

Fully-Specified Name

Component
Patient problem outcome
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Patient problem outcome

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
81215-6 Care plan - recommended C-CDA R2.0 and R2.1 sections
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) evolución del problema del paciente:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Resultado del problema del paciente:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Problèmes avenir patient:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Paziente, esito problema:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Пациент проблема исход:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 患者问题结局:发现:时间点:^患者:叙述型:
Synonyms: 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 病人问题结局;患者问题结果 病史与体格检查 难题;困难;棘手问题;麻烦;乱子;疑难问题;疑难

62387-6 Interventions Narrative

Term Description

This term was originally created for, though not limited in use to, the HL7 Implementation Guide for CDA: Progress Note. The Interventions section contains information about the specific interventions provided during the healthcare visit. Depending on the type of intervention(s) provided (procedural, education, application of assistive equipment, etc.), the details will vary but may include specification of frequency, intensity, and duration.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Interventions
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Interventions

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.34
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
81215-6 Care plan - recommended C-CDA R2.0 and R2.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Intervenciones:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Interventi:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Вмешательства:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 干预措施:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 干预措施类;干预 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验