Printer Friendly, PDF & Email

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

Additional Information

History & Physical

Applicable Standard(s)

  • History and Physical Note (LOINC® code 34117-2)


Log in or register to post comments