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

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  • 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
History & Physical
Description (*Please confirm or update this field for the new USCDI version*)

Summary of current and past conditions and observations used to inform an episode of care. (e.g. admission, surgery, or other procedure)

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 2.72
    • At minimum: Discharge Summary (LOINC® code 34117-2)

Comment

Submitted by dcarlson on

Wrong LOINC Description

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

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