| Level/ Type |
Code |
Display Name |
Code System |
Description |
| 0‑L |
10160-0
|
History of medication use
|
LOINC |
The medications section shall contain a description of the relevant medications for
the patient, e.g. an ambulatory prescription list. It shall include entries for medications
as described in the Entry Content Module. All prescribed medicine whose period of
time indicated for the treatment has not yet expired whether it has been dispensed
or not.
|
| 0‑L |
10162-6
|
History of pregnancies
|
LOINC |
|
| 0‑L |
10164-2
|
History of present illness
|
LOINC |
The history of present illness section shall contain a description of the sequence
of events preceding the patient’s current complaints. Step by step description of
ethiopathogenesis of current problem patient is being treated for.
|
| 0‑L |
11348-0
|
History of past illness
|
LOINC |
The History of Past Illness section shall contain a description of the conditions
the patient suffered in the past. It shall include entries for problems as described
in the Entry Content Modules. Illness which set on and resolved in the past.
|
| 0‑L |
11369-6
|
History of immunization
|
LOINC |
The immunizations section shall contain a description of the immunizations administered
to the patient in the past. It shall include entries for medication administration
as described in the Entry Content Modules. Active immunizations received in the past.
|
| 0‑L |
11450-4
|
Problem list
|
LOINC |
The active problem section shall contain a description of the conditions currently
being monitored for the patient. It shall include entries for patient conditions as
described in the Entry Content Module. Chronic, recurring or persistent illnesses,
requiring repeated reassessment and/or continuos/periodic therapy.
|
| 0‑L |
18776-5
|
Plan of treatment
|
LOINC |
The care plan section shall contain a description of the expectations for care including
proposals, goals, and order requests for monitoring, tracking, or improving the condition
of the patient. Therapeutic recommendations that do not include drugs
|
| 0‑L |
29554-3
|
Procedures
|
LOINC |
The procedure entry is used to record procedures that have occurred, or which are
planned for in the future.
|
| 0‑L |
29762-2
|
Social history
|
LOINC |
|
| 0‑L |
30954-2
|
Relevant diagnostic tests/laboratory data
|
LOINC |
|
| 0‑L |
46264-8
|
History of medical device use
|
LOINC |
The medical devices section contains text describing the patient history of medical
device use. Documented necessity to use a device replacing/supporting completely/partially
a body organ/organ system function.
|
| 0‑L |
47420-5
|
Functional status assessment
|
LOINC |
The Coded Functional Status Assessment Section provided a machine readable and description
of the patient’s status of normal functioning at the time the document was created.
Pain Scale Assessment, Braden Score Assessment, and Geriatric Depression Scale are
subsections of the Functional Status Assessment Section
|
| 0‑L |
47519-4
|
History of Procedures
|
LOINC |
The list of surgeries section shall include entries for procedures and references
to procedure reports when known as described in the Entry Content Modules. Surgical
or other invasive procedures in the past, on vital organs/body cavities/vascular or
central nervous system.
|
| 0‑L |
48765-2
|
Allergies, adverse reactions, alerts
|
LOINC |
The adverse and other adverse reactions section shall contain a description of the
substance intolerances and the associated adverse reactions suffered by the patient.
It shall include entries for intolerances and adverse reactions as described in the
Entry Content Modules Presence/absence of potentially life threatening reaction to
substances/factors, to which patient can be exposed in the environment, or during
treatment, of allergic or other known nature.
|
| 0‑L |
57828-6
|
Prescriptions
|
LOINC |
|
| 0‑L |
60590-7
|
Medication dispensed
|
LOINC |
|
| 0‑L |
8716-3
|
Physical findings
|
LOINC |
The vital signs section contains coded measurement results of a patient’s vital signs. |
|
Value Set epSOSSections 2013‑06‑03
