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.

Examples include but are not limited to admission, surgery, and 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 2.74
    • At minimum: History and Physical Note (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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