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

Data Element

History & Physical

Documents the current and past conditions and observations of the patient.

Applicable Vocabulary Standard(s)

Applicable Standards

Logical Observation Identifiers Names and Codes (LOINC®) version 2.70

  • Discharge Summary (LOINC® code 34117-2)


Wrong LOINC Description

The description of the LOINC 34117-2 should read "History & Physical note", not "Discharge Summary".

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