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Code
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Display
|
Definition
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social-history
|
Social
History
Social History
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The
Social
History
Observations
define
the
patient's
occupational,
personal
(e.g.
lifestyle),
social,
and
environmental
history
and
health
risk
factors,
as
well
as
administrative
data
such
as
marital
status,
race,
ethnicity
and
religious
affiliation.
The Social History Observations define the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.
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vital-signs
|
Vital
Signs
Vital Signs
|
Clinical
observations
measure
the
body's
basic
functions
such
as
such
as
blood
pressure,
heart
rate,
respiratory
rate,
height,
weight,
body
mass
index,
head
circumference,
pulse
oximetry,
temperature,
and
body
surface
area.
Clinical observations measure the body's basic functions such as such as blood pressure, heart rate, respiratory rate, height, weight, body mass index, head circumference, pulse oximetry, temperature, and body surface area.
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imaging
|
Imaging
|
Observations
generated
by
imaging.
The
scope
includes
observations,
plain
x-ray,
ultrasound,
CT,
MRI,
angiography,
echocardiography,
nuclear
medicine.
Observations generated by imaging. The scope includes observations, plain x-ray, ultrasound, CT, MRI, angiography, echocardiography, nuclear medicine.
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|
laboratory
|
Laboratory
|
The
results
of
observations
generated
by
laboratories.
Laboratory
results
are
typically
generated
by
laboratories
providing
analytic
services
in
areas
such
as
chemistry,
hematology,
serology,
histology,
cytology,
anatomic
pathology,
microbiology,
and/or
virology.
These
observations
are
based
on
analysis
of
specimens
obtained
from
the
patient
and
submitted
to
the
laboratory.
The results of observations generated by laboratories. Laboratory results are typically generated by laboratories providing analytic services in areas such as chemistry, hematology, serology, histology, cytology, anatomic pathology, microbiology, and/or virology. These observations are based on analysis of specimens obtained from the patient and submitted to the laboratory.
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procedure
|
Procedure
|
Observations
generated
by
other
procedures.
This
category
includes
observations
resulting
from
interventional
and
non-interventional
procedures
excluding
lab
and
imaging
(e.g.
cardiology
catheterization,
endoscopy,
electrodiagnostics,
etc.).
Procedure
results
are
typically
generated
by
a
clinician
to
provide
more
granular
information
about
component
observations
made
during
a
procedure,
such
as
where
a
gastroenterologist
reports
the
size
of
a
polyp
observed
during
a
colonoscopy.
Observations generated by other procedures. This category includes observations resulting from interventional and non-interventional procedures excluding lab and imaging (e.g. cardiology catheterization, endoscopy, electrodiagnostics, etc.). Procedure results are typically generated by a clinician to provide more granular information about component observations made during a procedure, such as where a gastroenterologist reports the size of a polyp observed during a colonoscopy.
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survey
|
Survey
|
Assessment
tool/survey
instrument
observations
(e.g.
Apgar
Scores,
Montreal
Cognitive
Assessment
(MoCA))
Assessment tool/survey instrument observations (e.g. Apgar Scores, Montreal Cognitive Assessment (MoCA))
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exam
|
Exam
|
Observations
generated
by
physical
exam
findings
including
direct
observations
made
by
a
clinician
and
use
of
simple
instruments
and
the
result
of
simple
maneuvers
performed
directly
on
the
patient's
body.
Observations generated by physical exam findings including direct observations made by a clinician and use of simple instruments and the result of simple maneuvers performed directly on the patient's body.
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therapy
|
Therapy
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Observations
generated
by
non-interventional
treatment
protocols
(e.g.
occupational,
physical,
radiation,
nutritional
and
medication
therapy)
Observations generated by non-interventional treatment protocols (e.g. occupational, physical, radiation, nutritional and medication therapy)
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Terminology
|
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