Version 2.82

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.

LOINC Names Get Info

Fully-Specified Name
Vital signs note:Find:Pt:^Patient:Doc:Observed
Long Common Name
Vital signs note
Short Name
Vital signs note

Part Model Get Info

  • Component
    Vital signs note
    LP448199-2
    • Analyte
      Vital signs note
      LP448199-2
      • Component Numerator
        Vital signs note
        LP448199-2
        • Component Numerator Core
          Vital signs note
          LP448199-2
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Find
    LP6813-2
  • Time
    Pt
    LP6960-1
    • Time Core
      Pt
      LP6960-1
    • Time Modifier
      NULL
       
  • System
    ^Patient
    LP310005-6
    • System Core
      NULL
       
    • Super System
      Patient
      LP6985-8
  • Scale
    Doc
    LP32888-7
  • Method
    Observed
    LP6425-5

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.81 (NAM)
Change Reason
Release 2.81: COMPONENT: updating the component to include "Note" accurately aligns with the EHDS Discharge Report Body’s requirements;
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 - Dokumentation:Befund:Zeitpunkt:^Patient:Dokument:Beobachtet
es-MX Spanish (Mexico) Signos vitales:Tipo:Punto temporal:^ Paciente:Narrativo:Observed
es-AR Spanish (Argentina) hallazgos físicos:hallazgo:punto en el tiempo:signos vitales:Narrativo:observado
it-IT Italian (Italy) Nota sui parametri vitali:Osservazione:Pt:^Paziente:Doc: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
zh-CN Chinese (China) 生命体征记录:发现:时间点:^患者:文档型:观察法
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 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 时刻;随机;随意;瞬间 生命体征类;生命征象 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书 观测法

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=8716-3