LOINC Code 78508-9: Cardiothoracic surgery Admission history and physical note

What is this code?

LOINC codes identify tests, measurements, observations, survey items, and clinical questions in a standardized way. It is associated with the component Admission history and physical note. It is commonly used with the system or sample type {Setting}.

When is it used?

• Used in lab systems, EHRs, and clinical data exchange.
• May identify a test, observation, survey item, or clinical document request rather than a diagnosis.
• Status: ACTIVE
• Order vs observation: Both
• Method: Thoracic and cardiac surgery

What it does not mean

• The code identifies the observation or test, not the actual result.

Key facts

• Cardiothoracic surgery Admission history and physical note
• Admission history and physical note
• Admit H&P note; Cardio; Cardiology; Cardiothor surg; DOC.ONT; Document; Encounter; Evaluation and management; Evaluation and management note; Finding; Findings; H&P note; Heart Disease; Hx; notes; Point in time; Random; Surg; Visit note

Where you may see this code

You may see this code in lab systems, lab reports, EHR exports, interoperability feeds, or other structured clinical data exchanges.

Common synonyms

Frequently asked questions