Physician History and physical note   28626-0

LOINC Code


LOINC code28626-0
namePhysician History and physical note
statusACTIVE

Fully-Specified Name

componentHistory and physical note
propertyFind  =  Finding
timePt  =  Point in time:  To identify measures at a point in time. This is a synonym for “spot” or “random” as applied to urine measurements.
system{Setting}
scaleDoc  =  Document:  A document that could be in many formats (XML, narrative, etc.)
methodPhysician

Additional Names

short nameMD H&P note

Basic Attributes

classDOC.ONTOLOGY
type2  Clinical
order vs. observationBoth

Ask At Order Entry

Ask at Order Entry (AOE) observations for a clinical observation or laboratory test. A LOINC term may represent a single AOE observation or a panel containing several AOE observations.

72228-0History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81243-8Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections

Associated Observations

LOINC codes that represent optional associated observation(s) for a clinical observation or laboratory test. A LOINC term may represent a single associated observation or panel containing several associated observations.

Member of these Groups

LG38753-6History and physical note|ANYRole|ANYSetting
LG38946-6Physician|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG41826-5{Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Member of these Panels

28563-5Care provider notes Set

History/Usage

first released
last updated2.58
last change typeMIN  - change to field other than name
change reasonChanged class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore being placed in this class.

Related Names

DOC.ONT
Document
Encounter
Evaluation and management
Evaluation and management note
Finding
Findings
H&P note
Hx
M.D.
MD
notes
Point in time
Random
Visit note

Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © 1995-2024, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://loinc.org/license for the full LOINC copyright and license.

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