Narrative patient data relevant to the context identified by note types.

Data Element

Additional Information

History & Physical
Description
Summary of current and past conditions and observations used to inform an episode of care. Examples include but are not limited to admission, surgery, and other procedure.

Applicable Vocabulary Standard(s)

Applicable Standards
  • Logical Observation Identifiers Names and Codes (LOINC®) version 2.73
    • At minimum: History and Physical Note (LOINC code 34117-2)

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