Version 2.78

10154-3 Chief complaint

Term Description

Chief complaint records the patient's primary complaint (the patient's own description).
Source: Regenstrief LOINC

Fully-Specified Name

Component
Chief complaint
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Reported

Additional Names

Short Name
Chief complaint Reported

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA 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
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
82811-1 Nurse summary note - recommended sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) motivo de consulta principal:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Queja principal:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Plainte principale:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Disturbo principale:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Disturbo primario Lamenta Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) belangrijkste klacht:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Основная жалоба:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Проблема;Заболевание Точка во времени;Момент
zh-CN Chinese (China) 主诉:发现:时间点:^患者:叙述型:报告法
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 控诉;申诉;指控;不平;牢骚;委屈;意见;怨言;病痛;主诉 时刻;随机;随意;瞬间 病史与体格检查

10164-2 History of present illness

Term Description

History of present illness describes the history related to the reason for a given procedure. It contains the historical details leading up to and pertaining to the patient's current complaint or reason for seeking medical care. Because history of present illness can include past surgical history and other procedures, the Procedure History section may be included under the History of Present Illness section or it may stand alone as its own section.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Present illness
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Pres illness

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63
Change Reason
Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA 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
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese der aktuellen Krankheit:Anamnese:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedentes de la enfermedad actual:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad presente:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Malattia attuale:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) huidige ziekte:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
zh-CN Chinese (China) 现有疾病:历史记录: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;史;病史 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 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 现病史;目前疾病;当前疾病;现病 病史与体格检查

11348-0 History of past illness

Term Description

History of past illness describes the history related to their current complaints, problems, or diagnoses.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Past illness
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Past illness

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63
Change Reason
Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA 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
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese früherer Krankheiten:Anamnese:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedentes de enfermedades pasadas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Enfermedad pasada:Hx:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Anamnèse. Maladies antérieures:Hx:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Malattie pregresse:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi Malattie passate paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) ziektegeschiedenis:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История предыдущих заболеваний:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез заболеваний История Описательный Точка во времени;Момент
zh-CN Chinese (China) 既往病史:历史记录: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;史;病史 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 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 既往疾病史;既往疾病历史 时刻;随机;随意;瞬间 病史与体格检查

56838-6 History of infection

Reference Information

Type Source Reference
Webcontent Integrating the Healthcare EnterpriseCopyright Copyright © 2009 IHE International.

Fully-Specified Name

Component
Infectious disease
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Infectious disease

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63
Change Reason
Previous Releases: Removed "History of" from Component and changed Property from "Find" to "Hx" per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Enfermedad infecciosa:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Malattia infettiva:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) besmettelijke ziekte:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
pt-BR Portuguese (Brazil) Histórico de doenças infecciosas:Achado:Pt:^Paciente:Nar:
Synonyms: ; Hx infectious disease; Finding; Findings; Point in time; Random; Narrative; Report; Dis
ru-RU Russian (Russian Federation) Инфекционная болезнь:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Точка во времени;Момент
zh-CN Chinese (China) 传染病:历史记录:时间点:^患者:叙述型:
Synonyms: 传染性疾病 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史;史;病史 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 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 疾 病 病史与体格检查 症

10162-6 Pregnancy history

Fully-Specified Name

Component
History of pregnancies
Property
Hx
Time
Pt
System
Reproductive system
Scale
Nar
Method

Additional Names

Short Name
Pregnancies Hx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63
Change Reason
Previous Releases: Changed Property from "Find" to "Hx" and removed Method of "Reported" per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

LOINC Long Common Name
81898-9 Composite triage and nursing note - recommended IHE set
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Anamnese früherer Schwangerschaften:Anamnese:Zeitpunkt:Reproduktionssystem:Freitext:
es-MX Spanish (Mexico) Historia de embarazos:Hx:Punto temporal:Sistema reproductivo:Narrativo:
es-AR Spanish (Argentina) antecedentes de embarazos:hallazgo:punto en el tiempo:sistema reproductor:Narrativo:informado
fr-BE French (Belgium) Anamnèse grossesses:Hx:Temps ponctuel:Système reproducteur:Narratif:
it-IT Italian (Italy) Storia di gravidanze:Hx:Pt:Apparato riproduttivo:Nar:
Synonyms: Anamnesi Apparato riproduttore Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) zwangerschapshistorie:voorgeschiedenis:moment:voortplantingsstelsel:tekstueel:
Synonyms: anamnese
ru-RU Russian (Russian Federation) История беременностей:Hx:ТчкВрм:Репродуктивная система:Опис:
Synonyms: Акушерский анамнез История Описательный Точка во времени;Момент
zh-CN Chinese (China) 妊娠史:历史记录:时间点:生殖系统:叙述型:
Synonyms: 历史;史;病史 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 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 怀孕;怀孕期;妊娠期;妊娠类;妊娠（复数） 怀孕史;妊娠历史 时刻;随机;随意;瞬间 病史与体格检查

29762-2 Social history

Term Description

The Social history section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Social history
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Social Hx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA 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
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Sozialanamnese:Befund:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) antecedentes sociales:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Historia social:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Histoire sociale:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Storia sociale:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) sociale geschiedenis:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Histórico social:Achado:Pt:^Paciente:Nar:
Synonyms: ; Social Hx; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Социальная история:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Социальный анамнез Точка во времени;Момент
zh-CN Chinese (China) 社会史: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 病史与体格检查 社会历史

10157-6 Coded family medical history

Term Description

History of family member diseases is a report of health information, including medical, genetic, environmental, and lifestyle factors, pertaining to the patient and his or her genetic relatives (living or deceased). The family history information is used to determine possible or relevant health risk factors that may have a potential impact on the patient's healthcare risk profile.
Source: Regenstrief LOINC

Fully-Specified Name

Component
History of family member diseases
Property
Hx
Time
Pt
System
^Family member
Scale
Nar
Method

Additional Names

Short Name
Family member diseases Hx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73
Change Reason
Previous Releases: Changed Property from "Find" to "Hx", removed Method of "Reported" and corrected System from Family to ^Family member to align with existing family history terms and to represent family member as a Super System per 8/2015 Clinical LOINC Committee decision;
Common Test Rank Get Info
9825

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA 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
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
35089-2 History and physical panel
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
35090-0 Patient history
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) antecedentes de enfermedades en miembros familiares:hallazgo:punto en el tiempo:familia:Narrativo:informado
es-MX Spanish (Mexico) Historia de enfermedades de miembros de la familia:Hx:Punto temporal:^ Miembro de la familia:Narrativo:
fr-BE French (Belgium) Anamnèse. Maladies dans la famille:Hx:Temps ponctuel:^membre de famille:Narratif:
fr-CA French (Canada) Antécédents familiaux:Histoire:Temps ponctuel:^membre de famille:Narratif:
it-IT Italian (Italy) Storia di malattie di membri familiari:Hx:Pt:^membro della famiglia:Nar:
Synonyms: Anamnesi Punto nel tempo (episodio) Storia di malattie di membri della famiglia Storia;Anamnesi
nl-NL Dutch (Netherlands) geschiedenis van ziekte binnen de familie:voorgeschiedenis:moment:^familielid:tekstueel:
Synonyms: anamnese ziekte in familieanamnese
ru-RU Russian (Russian Federation) История член семьи заболевания:Hx:ТчкВрм:^семьи член:Опис:
Synonyms: История Описательный Семейный анамнез заболеваний Точка во времени;Момент
zh-CN Chinese (China) 家族成员疾病史:历史记录:时间点:^家庭成员:叙述型:
Synonyms: 历史;史;病史 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 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 家人;家族成员;超系统 - 家庭成员 家庭 家族成员病史;家属疾病史;家属病史;家庭成员疾病史;家庭成员病史 时刻;随机;随意;瞬间 病史与体格检查

10187-3 Review of systems

Term Description

The Review of systems section contains a relevant collection of symptoms and functions systematically gathered by a clinician. It includes symptoms the patient is currently experiencing, some of which were not elicited during the history of present illness, as well as a potentially large number of pertinent negatives, for example, symptoms that the patient denied experiencing.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Review of systems
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Reported

Additional Names

Short Name
Review of systems

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA 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
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) revisión de sistemas:hallazgo:punto en el tiempo:^paciente:Narrativo:informado
es-MX Spanish (Mexico) Revisión de sistemas:Tipo:Punto temporal:^ Paciente:Narrativo:Reported
fr-BE French (Belgium) Revue des systèmes:Observation:Temps ponctuel:^Patient:Narratif:Rapporté
it-IT Italian (Italy) Esame di apparati:Osservazione:Pt:^Paziente:Nar:Riportato
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) beoordeling van systemen:bevinding:moment:^patiënt:tekstueel:rapportage
ru-RU Russian (Russian Federation) Исследование по системам:Находка:ТчкВрм:^Пациент:Опис:Сообщенный
Synonyms: Анамнестические сведения;Сообщенная третьим лицом информация Описательный Точка во времени;Момент
zh-CN Chinese (China) 系统评审:发现:时间点:^患者:叙述型:报告法
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 病史与体格检查 系统回顾;系统审核

29545-1 Physical exam

Fully-Specified Name

Component
Physical findings
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Observed

Additional Names

Short Name
Phys find

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
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
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
74449-0 Patient plan of care - recommended IHE set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:^paciente:Narrativo:observado
es-MX Spanish (Mexico) Hallazgos físicos:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
fr-BE French (Belgium) Examen physique:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Osservazioni fisiche:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichamelijke bevindingen:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:^Paciente:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Физикальные находки:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 体格检查发现:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查（查体、体检、身体检查、肉体检查）发现（所见）;查体发现;查体所见 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 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 观测法

8716-3 Vital signs

Term Description

The Vital signs section includes blood pressure, body temperature, heart rate, and respiratory rate. It may also include other clinical findings, such as height, weight, body mass index, head circumference, and pulse oximetry. In particular, notable vital signs or physical findings such as the most recent, maximum and/or minimum, baseline, or relevant trends may be included.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Vital signs
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method
Observed

Additional Names

Short Name
Vital signs

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.73
Common Test Rank Get Info
576

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
81898-9 Composite triage and nursing note - recommended IHE set
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA 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
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
92575-0 Labor and delivery admission history and physical - recommended IHE set
57083-8 Labor and Delivery record panel
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
82811-1 Nurse summary note - recommended sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Vitalparameter:Befund:Zeitpunkt:^Patient:Freitext:Beobachtet
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:signos vitales:Narrativo:observado
es-MX Spanish (Mexico) Signos vitales:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
fr-BE French (Belgium) Signes vitaux:Observation:Temps ponctuel:^Patient:Narratif:Observé
it-IT Italian (Italy) Segni vitali:Osservazione:Pt:^Paziente:Nar:Osservato
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) vitale functies:bevinding:moment:^patiënt:tekstueel:observatie
pt-BR Portuguese (Brazil) Achados físicos:Achado:Pt:Sinais vitais:Nar:Observado
Synonyms: ; Phys find; Exam; Examination; Finding; Point in time; Random; Narrative; Report; Observ
ru-RU Russian (Russian Federation) Жизненно важные функции:Находка:ТчкВрм:^Пациент:Опис:Наблюдённый
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 生命体征:发现:时间点:^患者:叙述型:观察法
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 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 生命体征类;生命征象 病史与体格检查 观测法