NIH Common Data Elements (CDE) Repository

General Details:

Name:: History general Narrative - Reported
Steward:: LOINC
Definition:: History general describes all aspects of medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. It may also be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Past Medical History and Social History.
Registration Status:: Qualified

Value	Code Name	Code	Code System	Code Description

Definition:: History general describes all aspects of medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. It may also be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Past Medical History and Social History.
Tags:: Source: Regenstrief LOINC

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Related Names

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Related Codes

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Code System	Code	Code Text	Code Version
https://www.phenxtoolkit.org	PX221201090000	PX221201_Growth_Chart_Notable_Comments		https://www.phenxtoolkit.org	PX221201140000	PX221201_Growth_Chart_Current_Notable_Comments

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Fully-Specified Name

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Component	Property	Time	System	Scale	Method
History general	Find	Pt	^Patient	Nar	Reported

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Basic Attributes

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Class	Type	First Released	Last Updated	Change Reason
H&P.HX	Clinical	Version 1.0j-a	Version 2.63	Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.