Narrative patient data relevant to the context identified by note types.
- Usage note: Clinical Notes data elements are content exchange standard agnostic. They should not be interpreted or associated with the structured document templates that may share the same name.
Data Element |
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History & Physical
Description
Documents the current and past conditions and observations of the patient. Applicable Vocabulary Standard(s) Applicable Standards (*Please confirm or update this field for the new USCDI version*)
Logical Observation Identifiers Names and Codes (LOINC®) version 2.67
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Submitted by dcarlson on
Wrong LOINC Description
The description of the LOINC 34117-2 should read "History & Physical note", not "Discharge Summary".