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Clinical Notes

Composed of both structured (i.e. obtained via pick-list and/or check the box) and unstructured (free text) data. A clinical note may include the history, Review of Systems (ROS), physical data, assessment, diagnosis, plan of care and evaluation of plan, patient teaching and other relevant data points.

Data Element

Applicable Standards(s)

Consultation Note
  • Consult Note (LOINC® code 11488-4)
Discharge Summary Note
  • Discharge Summary (LOINC® code 18842-5)
History & Physical
  • History and Physical Note (LOINC® code 34117-2)
Imaging Narrative
  • Diagnostic Imaging Study (LOINC® code 18748-4)
Laboratory Report Narrative
Pathology Report Narrative
Procedure Note
  • Procedure Note (LOINC® code 28570-0)
Progress Note
  • Progress Note (LOINC® code 11506-3)

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