History and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections:-:Pt:{Setting}:-:

Preferred Label : History and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections:-:Pt:{Setting}:-:;

LOINC status : ACTIVE;

LOINC long common name : History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections;

LOINC short name : H P C-CDA R1.1 2.0 2.1 Sections;

LOINC description : This panel contains the recommended sections for history and physical notes based on the HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.;

Details

Origin ID

72228-0;

UMLS CUI

C3496497;

Has component
- History and physical note [LOINC component]
- History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections [LOINC component]
- Note [LOINC component]
Has system
- {Setting} [LOINC System]
Has time aspect
- Point in time (spot) [LOINC time aspect]
Panel of LOINC codes
- Allergies &or adverse reactions:Find:Pt:^Patient:Doc: [LOINC code]
- Chief complaint+Reason for visit:Find:Pt:^Patient:Nar: [LOINC code]
- Chief complaint:Find:Pt:^Patient:Nar:Reported [LOINC code]
- Evaluation note:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Evaluation+Plan note:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- History of family member diseases:Hx:Pt:^Family member:Nar: [LOINC code]
- History of procedures:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Immunization:Hx:Pt:^Patient:Nar: [LOINC code]
- Instructions:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Medication use:Hx:Pt:^Patient:Nar: [LOINC code]
- Past illness:Hx:Pt:^Patient:Nar: [LOINC code]
- Physical findings:Find:Pt:General status:Nar:Observed [LOINC code]
- Physical findings:Find:Pt:^Patient:Nar:Observed [LOINC code]
- Plan of care note:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Present illness:Hx:Pt:^Patient:Nar: [LOINC code]
- Problem list:Find:Pt:^Patient:Nom:Reported [LOINC code]
- Reason for visit:Find:Pt:^Patient:Nar: [LOINC code]
- Relevant diagnostic tests &or laboratory data:Find:Pt:^Patient:Nar: [LOINC code]
- Review of systems:Find:Pt:^Patient:Nar:Reported [LOINC code]
- Social history:Find:Pt:^Patient:Nar: [LOINC code]
- Vital signs:Find:Pt:^Patient:Nar:Observed [LOINC code]
Semantic type(s)
- Clinical Attribute [UMLS semantic type]

Keyword's position in hierarchy(ies) :

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