Version 2.78

8648-8 Hospital course

Term Description

Hospital course describes the sequence of events from admission to discharge in a hospital facility.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Hospital course
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hospital course

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
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
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set
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) curso hospitalario:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Curso hospitalario:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Séjour hospitalier:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Decorso ospedaliero:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis verloop:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Curso do hospital:Achado:Pt:^Paciente:Nar:
Synonyms: Hosp; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Госпитальный курс:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Курс лечения в стационаре Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院病程: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 医院过程;住院治疗情况记录 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 病院 院

42348-3 Coded advanced directives

Term Description

Advance directives contains data defining the patient's direction of care and any reference to supporting documentation. The most recent and up-to-date directives are required, if known, and should be listed in as much detail as possible. Advance directives contains data such as the existence of living wills, healthcare proxies, and CPR and resuscitation status.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Advance directives
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Advance directives

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.16
Last Updated
Version 2.67
Change Reason
Previous Releases: Based on Clinical LOINC Committee review at the Feb. 2016 meeting, this term represents a document containing information on a patient's advance directives and any supporting documentation, such as a living will. The term was revised to fit the current LOINC Document Ontology model.;
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel
69459-6 Care record summary panel
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
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
71531-8 ESRD hospitalization panel
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
82811-1 Nurse summary note - recommended sections
74449-0 Patient plan of care - recommended IHE set
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

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG51615-9 Advance directives|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Patientenverfügung:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
de-AT German (Austria) Patientenverfügung:Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}
Synonyms: Beachtliche und verbindliche Patientenverfügungen
es-MX Spanish (Mexico) Directivas avanzadas:Tipo:Punto temporal:{Configuración}:Documento:{Role}
fr-CA French (Canada) Directives médicales anticipée:Observation:Temps ponctuel:{Situation}:Document:{Rôle}
it-IT Italian (Italy) Dichiarazioni anticipate di trattamento:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato Testamenti biologici;Direttive anticipate
nl-NL Dutch (Netherlands) wilsverklaring:bevinding:moment:{instelling}:document:{rol}
pt-BR Portuguese (Brazil) Diretivas avançadas:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
zh-CN Chinese (China) 事前指示类:发现:时间点:{环境}:文档型:{角色}
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 事前指示;事前意愿;事前要求;遗嘱;遗愿 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 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 未加明确说明的角色

11535-2 Discharge diagnosis

Term Description

Hospital discharge diagnosis describes the patient's relevant problems or diagnoses that occurred during the hospitalization or that need to be followed after hospitalization.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Hospital discharge Dx
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hospital discharge Dx

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 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
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set
82811-1 Nurse summary note - recommended 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) diagnóstico al alta del hospital:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Alta hospitalaria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Documents sortie hôpital:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, Dx:Imp:Pt:^Paziente:Nar:
Synonyms: Anamnesi Diagnosi di dimissione ospedaliera Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis onslagdiagnose:interpretatie:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Alta hospitalar Dx:Imp:Pt:^Paciente:Nar:
Synonyms: Hosp; Interpretation; Interp; Impression; Impressions; Point in time; Random; Narrative; Report; Diagnosis
ru-RU Russian (Russian Federation) Госпитализация выбытие Dx:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Выписка Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院诊断:印象:时间点:^患者:叙述型:
Synonyms: Dx 允许...离开(医院、军队);(从监狱)释放 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 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 病史与体格检查 病院 诊断（Diagnosis，Dx） 院

10183-2 Hospital discharge medications

Term Description

Hospital discharge medications defines the medications that the patient is intended to take (or stop) after discharge. This may also include a patient's prescription history and indicate the source of the medication list, for example, from a pharmacy system versus from the patient.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Hospital discharge medications
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hospital discharge medications

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
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 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
59271-7 Hospital discharge summary panel
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Medicamentos para el alta hospitalaria:Tipo:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) medicación para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:
fr-BE French (Belgium) Médications sortie hôpital:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, farmaci:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Farmaci di dimissione ospedaliera Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ziekenhuis ontslagmedicatie:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Госпитализация выбытие лекарственные препараты:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Выписка Лекарства Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院药物:发现:时间点:^患者:叙述型:
Synonyms: 允许...离开(医院、军队);(从监狱)释放 出院药物（用药、药物治疗、药物处理） 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 医院出院后用药 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 病院 药物类;处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 院

30954-2 Coded results

Fully-Specified Name

Component
Relevant diagnostic tests &or laboratory data
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Relevant Dx tests/lab data

Basic Attributes

Class
VACCIN
Type
Clinical
First Released
Version 2.04
Last Updated
Version 2.63
Order vs. Observation
Observation

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
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
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
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE 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
102087-4 Secretin stimulation/Gastrin XXX challenge panel
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Relevante diagnostische Tests &oder Labordaten:Befund:Zeitpunkt:^Patient:Freitext:
es-AR Spanish (Argentina) pruebas diagnósticas relevantes y/o información de laboratorio:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Pruebas de diagnóstico o datos de laboratorio relevantes:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Test de diagnostic utiles et données de laboratoire:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Test diagnostici rilevanti &o dati di laboratorio:Osservazione:Pt:^Paziente:Nar:
Synonyms: Osservazione paziente Punto nel tempo (episodio) Test diagnostici rilevanti/dati di laboratorio Vaccinazioni
nl-NL Dutch (Netherlands) relevante diagnostische tests en/of laboratoriumgegevens:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Testes diagnósticos relevantes e/ou dados laboratóriais:Achado:Pt:^Paciente:Nar:
Synonyms: ; Relevant Dx tests/lAc data; Finding; Findings; Point in time; Random; Narrative; Report; VACCINE
ru-RU Russian (Russian Federation) Значимый диагностический тест &или лабораторные данные:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 相关诊断试验和或实验室数据: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 接种;接种记录;疫苗;疫苗接种 时刻;随机;随意;瞬间 检验科;化验室;化验科 相关诊断试验/实验室数据;相关诊断试验和或实验室资料;相关诊断试验和或实验室检验数据;相关诊断试验和或检验数据;相关诊断试验和或化验数据

11493-4 Coded hospital discharge studies summary

Fully-Specified Name

Component
Hospital discharge studies summary
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hospital discharge studies summary

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
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
59271-7 Hospital discharge summary panel
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) resumen de los estudios para el alta del hospital:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Resumen de estudios de alta hospitalaria:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Résumé des études de sortie hospitalière:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Dimissione ospedaliera, sintesi esami:Osservazione:Pt:^Paziente:Nar:
Synonyms: Anamnesi Osservazione paziente Punto nel tempo (episodio) Sintesi esami in dimissione ospedaliera
nl-NL Dutch (Netherlands) ziekenhuis ontslag samenvatting onderzoeken:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Госпитализация выбытие исследования краткие сведения:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Выписка Описательный Точка во времени;Момент
zh-CN Chinese (China) 医院出院检查摘要:发现:时间点:^患者:叙述型:
Synonyms: 允许...离开(医院、军队);(从监狱)释放 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 医院出院检查摘要（小结、概要、总结、梗概、概括、总汇） 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 病院 院

38212-7 Pain scale assessment

Fully-Specified Name

Component
Pain assessment panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Additional Names

Short Name
Pain Assessment Pnl

Basic Attributes

Class
PANEL.H&P
Type
Clinical
First Released
Version 2.13
Last Updated
Version 2.69
Order vs. Observation
Order
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
57083-8 Labor and Delivery record panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) PAIN ASSESSMENT PANEL:-:punto en el tiempo:^PATIENT:-:
es-MX Spanish (Mexico) Panel de evaluación del dolor:-:Punto temporal:^ Paciente:-:
it-IT Italian (Italy) Dolore, panel valutazione:-:Pt:^Paziente:-:
Synonyms: Panel valutazione del dolore paziente Punto nel tempo (episodio) Set di prescrizione per anamnesi e esame obiettivo Valutazione del dolore
nl-NL Dutch (Netherlands) pijn vaststellingspanel:-:moment:^patiënt:-:
pt-BR Portuguese (Brazil) Avaliação da dor painel:-:Pt:^Paciente:-:
Synonyms: ; Pain Assessment Pnl; Point in time; Random; Pan; Panl
ru-RU Russian (Russian Federation) Боль оценка панель:-:ТчкВрм:^Пациент:-:
Synonyms: Точка во времени;Момент
zh-CN Chinese (China) 疼痛评估组套:-:时间点:^患者:-:
Synonyms: 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.病史与体格检查小节;组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目）.历史纪录与体格检查;医嘱组.历史纪录与体格检查小节;医嘱组.病史与体格检查;历史纪录与体格检查医嘱组;历史纪录与体格检查医嘱组类;历史纪录与体格检查小节医嘱组;历史纪录与体格检查小节医嘱组类;病史与体格检查医嘱组;病史与体格检查医嘱组类;病史与体格检查小节医嘱组;病史与体格检查小节医嘱组类 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 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 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 疼;痛;痛苦;悲痛;苦恼 疼痛评估（评价、估计、估价、评论、估定、估算） 疼痛评估（评价、估计、估价、评论、估定、估算）组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目） 病史与体格检查 组 组合 组合医嘱 组合类 组套 评价;估计;估价;评论;估定;估算

38227-5 Braden score

Fully-Specified Name

Component
Braden scale score.total
Property
Score
Time
Pt
System
^Patient
Scale
Qn
Method
Observed.Braden scale

Additional Names

Short Name
Braden Scale Total Score

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.13
Last Updated
Version 2.73
Change Reason
Previous Releases: We made an administrative decision to define the total scores from various survey instruments as Quantitative rather than ordinal. There is no intention to change the existing meaning.;
Common Test Rank Get Info
866

Member of these Panels

LOINC Long Common Name
38228-3 Braden scale skin assessment panel
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Example Units

Unit Source
{score} Example UCUM Units

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

57076-2 Post-partum treatment

Term Description

The Post-partum Treatment Section shall include a narrative description of the treatment delivered to the mother susequent to the delivery.
Source: Regenstrief LOINC

Reference Information

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

Fully-Specified Name

Component
Postpartum hospitalization treatment
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Postpartum hospitalization treatment

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Tratamiento de hospitalización posparto:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Post-partum, terapia ricovero:Osservazione:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio) Storia di ospedalizzazioni Trattamento in ricovero post parto;Trattamento in
nl-NL Dutch (Netherlands) ziekenhuisbehandeling post partum:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Tratamento hospitalar pós-parto:Achado:Pt:^Paciente:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report; Postpartm; Postpart
ru-RU Russian (Russian Federation) Послеродовая госпитализация лечение:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Анамнез госпитализаций Описательный Точка во времени;Момент
zh-CN Chinese (China) 产后住院治疗:发现:时间点:^患者:叙述型:
Synonyms: 产后医院治疗;产后住院治疗治疗手段（方法、措施） 产后的 住院治疗历史; 医院收容史;送入医院;留诊史;住院史 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 在产后 时刻;随机;随意;瞬间 病史与体格检查

57072-1 Intravenous fluids administered

Term Description

The intravenous fluids administered section shall contain a narrative description of fluids administered to a patient during the course of an encounter.
Source: Regenstrief LOINC

Reference Information

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

Fully-Specified Name

Component
Intravenous fluids administered
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
IV fluids administered

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
81898-9 Composite triage and nursing note - 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

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Se administran líquidos por vía intravenosa:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Liquidi intravenosi somministrati:Osservazione:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) intraveneus toegediende vloeistoffen:bevinding:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Líquidos intravenosos administrados:Achado:Pt:^Paciente:Nar:
Synonyms: ; IV fluids administered; Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Внутривенные жидкости введены:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Точка во времени;Момент
zh-CN Chinese (China) 所施用的静脉内液体:发现:时间点:^患者:叙述型:
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 所给予的静脉内（静脉内注射、静注、IV）液体（输液） 时刻;随机;随意;瞬间 病史与体格检查

55103-6 Estimated blood loss

Fully-Specified Name

Component
Surgical operation note estimated blood loss
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Operative note estimated blood loss

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92574-3 Labor and delivery summary - recommended IHE set
92576-8 Maternal discharge summary - recommended IHE set
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de operación quirúrgica pérdida de sangre estimada:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Nota di operazione chirurgica, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:
Synonyms: Nota di intervento chirurgico Osservazione paziente Perdita di sangue stimata in nota di intervento ch Procedura chirurgica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag geschat bloedverlies:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Послеоперационный эпикриз Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录 预计失血量: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.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 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 失血量;出血;出血量;血液损失 手术操作记录 预计失血量;外科手术操作记录 预计失血量;手术记录 预计失血量;外科手术记录 估计失血量;外科手术记录 预计失血 手术操作记录;外科手术操作记录;手术记录 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书 血;全血

56836-0 Transfusion history

Reference Information

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

Fully-Specified Name

Component
Blood transfusion
Property
Hx
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Hx of Blood transfusion

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.73
Change Reason
Previous Releases: Removed "History of" from Component and changed Property from "Find" to "Hx" per 8/2015 Clinical LOINC Committee decision;
Common Test Rank Get Info
10793

Member of these Panels

LOINC Long Common Name
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Transfusión de sangre:Hx:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Trasfusione di sangue:Hx:Pt:^Paziente:Nar:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Storia;Anamnesi
nl-NL Dutch (Netherlands) bloedtransfusie:voorgeschiedenis:moment:^patiënt:tekstueel:
Synonyms: anamnese
pt-BR Portuguese (Brazil) Histórico de transfusões sanguíneas:Achado:Pt:^Paciente:Nar:
Synonyms: ; Hx blood transfusion; Finding; Findings; Point in time; Random; Narrative; Report; Tx
ru-RU Russian (Russian Federation) История крови переливания:Hx:ТчкВрм:^Пациент:Опис:
Synonyms: История Описательный Точка во времени;Момент Трансфузионный анамнез
zh-CN Chinese (China) 输血: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 注入 灌输 病史与体格检查 血;全血 血库成分 - 输血 输注 输液 输血史;血液输注 输血法

34895-3 Patient education and consents

Fully-Specified Name

Component
Education note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Educ note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.11
Last Updated
Version 2.73
Change Reason
Previous Releases: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;
Order vs. Observation
Both
Common Test Rank Get Info
4357

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38762-7 Education note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) EDUCATION NOTE:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}
es-MX Spanish (Mexico) Nota educativa:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Nota educativa:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) opleidingsverslag:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 教育记录:发现:时间点:{环境}:文档型:{角色}
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 教育（培训、训练）记录;培训记录;训练记录 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 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书

57077-0 Newborn status at maternal discharge

Term Description

The Newborn Status at Maternal Discharge section shall contain a narrative description of the status and disposition of the newborn at the time of maternal discharge.
Source: Regenstrief LOINC

Part Descriptions

LP281763-5   ^Newborn
Newborn refers to an infant during the hospital stay in which he/she was born. Terms with "Newborn" are used for concepts recorded in the mother's record. Source: Regenstrief LOINC

Reference Information

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

Fully-Specified Name

Component
Newborn status at maternal discharge
Property
Find
Time
Pt
System
^Newborn
Scale
Nar
Method

Additional Names

Short Name
NB status at maternal discharge NB

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
57083-8 Labor and Delivery record panel
92576-8 Maternal discharge summary - recommended IHE set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Estado del recién nacido al alta de la madre:Tipo:Punto temporal:^ Recién nacido:Narrativo:
it-IT Italian (Italy) Neonato, stato alla dimissione della madre:Osservazione:Pt:^neonato:Nar:
Synonyms: Esame obbiettivo Osservazione Punto nel tempo (episodio) Stato del neonato al momento della dimissione dell
nl-NL Dutch (Netherlands) status nieuwgeborene bij ontslag moeder:bevinding:moment:^pasgeborene:tekstueel:
pt-BR Portuguese (Brazil) Estado do recém nascido na alta materna:Achado:Pt:^Recem nascido:Nar:
Synonyms: ; NB status at maternal discharge; Finding; Findings; Point in time; Random; New born; Narrative; Report
ru-RU Russian (Russian Federation) Новорождённый статус при мать выбытие:Находка:ТчкВрм:^новорожденный:Опис:
Synonyms: Выписка Описательный Состояние новорождённого при выписке матери Точка во времени;Момент
zh-CN Chinese (China) 产妇出院时的新生儿状态:发现:时间点:^新生儿:叙述型:
Synonyms: 产妇出院时的新生儿状况 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 允许...离开(医院、军队);(从监狱)释放 初生儿;超系统 - 新生儿 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 状况;情况 病史与体格检查