LOINC Home

{component}   LP432695-7

Clinical   LP7787-7

Clinical terms not yet categorized   LP248771-0

History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections   72228-0

LOINC Code


LOINC code72228-0
nameHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
descriptionThis 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.
statusACTIVE

Fully-Specified Name

componentHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections
property-
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}
scale-
method

Additional Names

short nameH+P C-CDA R1.1+2.0+2.1 Sections

Basic Attributes

classPANEL.DOC
type2  Clinical

Panel Components

48765-2Allergies and adverse reactions Document
51848-0Evaluation note
51847-2Evaluation + Plan note
10154-3Chief complaint Narrative - Reported
10157-6History of family member diseases Narrative
10210-3Physical findings of General status Narrative
10164-2History of Present illness Narrative
11369-6History of Immunization Narrative
69730-0Instructions
10160-0History of Medication use Narrative
11348-0History of Past illness Narrative
29545-1Physical findings Narrative
18776-5Plan of care note
11450-4Problem list - Reported
47519-4History of Procedures Document
29299-5Reason for visit Narrative
46239-0Chief complaint+Reason for visit Narrative
30954-2Relevant diagnostic tests/laboratory data Narrative
10187-3Review of systems Narrative - Reported
29762-2Social history Narrative
8716-3Vital signs

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.

History/Usage

first released
last updated2.56
last change typeNAM  - change to Analyte/Component
change reasonChanged Component name to reflect that this convenience panel contains recommended sections for C-CDA 1.1, 2.0 and 2.1.

Related Names

Congenital dyserythropoietic anaemia
Encounter
Evaluation and management
Evaluation and management note
H&P note
H+P C-CDA R1.1+2.0+2.1 Sections
Hx
notes
 Pan
Panel
PANEL.DOC
Panl
Pnl
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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