| 11368-8 | Illness or injury onset date and time | |
| 11374-6 | Injury incident description | |
| 11373-8 | Injury cause | |
| 11376-1 | Injury location | |
| 11372-0 | Injury associated activity | |
| 11375-3 | Injury intent | |
| 11457-9 | Safety equipment used | |
| 10160-0 | Hx of Medication use | |
| 48766-0 | Source of info | |
| 10154-3 | Chief complaint Reported | |
| 29299-5 | Reason for visit | |
| 56817-0 | Presenting problem | |
| 10164-2 | Hx of Pres illness | |
| 56818-8 | Problem description | |
| 56819-6 | Problem prior evaluation | |
| 56865-9 | Problem diagnostic considerations | |
| 56820-4 | Problem context | |
| 56821-2 | Problem exacerbating factors | |
| 38211-9 | Pain initiating event Reported | |
| 55258-8 | Problem alleviating factors | |
| 38210-1 | Pain alleviating factors Reported | |
| 56822-0 | Problem response to therapy | |
| 56823-8 | Problem quality or description | |
| 32419-4 | Pain quality | |
| 56824-6 | Problem location | |
| 38204-4 | Pain primary location Reported | |
| 38205-1 | Pain radiation | |
| 56825-3 | Problem time course | |
| 38206-9 | Pain temporal pattern Reported | |
| 56826-1 | Problem frequency | |
| 56827-9 | Sym dur during occurrences or episodes | |
| 38207-7 | Pain duration Reported | |
| 56866-7 | Onset of painful contractions | |
| 56828-7 | Time contractions became regular | |
| 56829-5 | Time membranes ruptured | |
| 55259-6 | Time last ate solid food | |
| 55260-4 | Time last drank liquid | |
| 56830-3 | Limitations in obtaining history | |
| 56831-1 | Problem associated signs+symptoms | |
| 11450-4 | Problem list Reported | |
| 11348-0 | Hx of Past illness note | |
| 11323-3 | General health Reported | |
| 11338-1 | Hx of Major illnesses and injuries | |
| 10162-6 | Pregnancies Hx | |
| 48765-2 | Allergies &or adverse reactions Doc | |
| 44939-7 | Hx of Adverse drug rxn | |
| 11382-9 | Medication allergy Reported | |
| 10167-5 | Hx of Surg proc | |
| 46239-0 | Chief complaint+Reason for visit | |
| 11336-5 | Hx of Hospitalization | |
| 10156-8 | Hx of Childhood diseases | |
| 11346-4 | Hx of Outpt visits | |
| 46264-8 | Hx medical device use | |
| 10155-0 | Hx of Allergies | |
| 11334-0 | Hx of Growth+Development | |
| 11370-4 | Immunization status Reported | |
| 11369-6 | Hx of Immunization note | |
| 11458-7 | C tetani immunization status | |
| 55261-2 | RABV immunization status | |
| 55262-0 | FLUV immunization status | |
| 55263-8 | B pert immunization status | |
| 55264-6 | HAV immunization status | |
| 55265-3 | MeV status | |
| 55266-1 | HIB immunization status | |
| 55267-9 | HPV immunization status | |
| 55268-7 | RV immunization status | |
| 55269-5 | N men immunization status | |
| 55270-3 | S pneum polyvalent immunization status | |
| 55271-1 | S pneum conjugated immunization status | |
| 55272-9 | C diphtheriae immunization status | |
| 55273-7 | PV immunization status | |
| 55274-5 | VZV status | |
| 55275-2 | HBV status | |
| 55276-0 | HCV status | |
| 55277-8 | HIV status | |
| 55278-6 | RUBV status | |
| 55279-4 | CMV status | |
| 11320-9 | Feeding and dietary status Reported | |
| 47420-5 | Functional status note | |
| 11332-4 | Hx of Cogn func | |
| 29762-2 | Social hx note | |
| 11380-3 | Marital status+living arrang | |
| 11294-6 | Current employment Reported | |
| 11340-7 | Hx of Occupation | |
| 10161-8 | Hx of Occupational exposure | |
| 55280-2 | Military service | |
| 11330-8 | Hx of Alcohol use | |
| 11287-0 | Alcoholic drinks/drinking D Reported | |
| 11286-2 | Alcohol binge episodes/M Reported | |
| 44940-5 | Alcoholic drinks per W Reported | |
| 11366-2 | Hx of Tobacco use | |
| 8663-7 | Cigs smoked (pack/day) nRate Reported | |
| 8664-5 | Cigs smoked (pack/year) nRate Reported | |
| 11342-3 | Hx of Other nonmedical drug use | |
| 56832-9 | Type of substance abused | |
| 82589-3 | Highest level of educ | |
| 11350-6 | Hx of Sexual behavior | |
| 10182-4 | Hx of Travel note | |
| 11344-9 | Other social factors Hx | |
| 10157-6 | Hx of fam member ds note | |
| 10187-3 | Review of systems | |
| 56872-5 | Constitutional symptoms | |
| 8672-8 | Hx of Neurologic disorders | |
| 11358-9 | Hx of Psychiatric disorders | |
| 10170-9 | Hx of Endocrine disorders | |
| 10172-5 | Hx of Hematologic disorders | |
| 11352-2 | Hx of Allergy+Immunologic disorders | |
| 56836-0 | Hx of Blood transfusion | |
| 56837-8 | Hx of Neoplastic disease | |
| 56838-6 | Hx of Infectious disease | |
| 11357-1 | Hx of Integumentary disorders | |
| 10178-2 | Hx of Skin disorders | |
| 11353-0 | Hx of Brsts disorders | |
| 10171-7 | Hx of Eyes disorders | |
| 11354-8 | Hx of ENSMT disorders | |
| 10169-1 | Hx of Ear disorders | |
| 10174-1 | Hx of Nose disorders | |
| 10168-3 | Hx of CVS disorders | |
| 10175-8 | Hx of Oral cavity disorders | |
| 10177-4 | Hx of Respiratory disorders | |
| 11355-5 | Hx of GI disorders | |
| 11356-3 | Hx of GU disorders | |
| 10176-6 | Hx of Reproductive disorders | |
| 10181-6 | Hx of Urinary disorders | |
| 10176-6 | Hx of Reproductive disorders | |
| 56871-7 | Hx of Gynecologic system disorders | |
| 49033-4 | Menstrual Hx Reported | |
| 8678-5 | Menstrual status Reported | |
| 8659-5 | Birth control method Reported | |
| 8665-2 | LMP Start date | |
| 56833-7 | Pregnancy related history | |
| 11778-8 | Deliv date Clin est | |
| 11996-6 | Pregnancies | |
| 11977-6 | Parity | |
| 10181-6 | Hx of Urinary disorders | |
| 55281-0 | # Fetuses | |
| 56834-5 | Fet Movement | |
| 56835-2 | Viability of current pregnancy | |
| 11449-6 | Pregnancy status Reported | |
| 55282-8 | Date symptoms of pregnancy 1st noted | |
| 10173-3 | Hx of Musculoskeletal disorders | |
| 29545-1 | Physical findings note | |
| 9272-6 | 1M Apgar Score | |
| 9274-2 | 5M Apgar Score | |
| 9271-8 | 10M Apgar Score | |
| 10210-3 | Phys find General status | |
| 56839-4 | Acuity assess | |
| 8716-3 | Vital signs note | |
| 38208-5 | Pain severity Reported | |
| 38214-3 | Pain severity Scre VAS | |
| 38221-8 | Pain severity Wong-Baker FACES Scale | |
| 38215-0 | Pain severity total Scre FLACC | |
| 56840-2 | Pain severity verbal numeric scale Scre | |
| 56840-2 | Pain severity verbal numeric scale Scre | |
| 38203-6 | Speed of pain onset Reported | |
| 56842-8 | Chronic pain assessment | |
| 44971-0 | Capillary refill Time | |
| 59408-5 | SaO2 % BldA PulseOx | |
| 3151-8 | Inhaled O2 flow rate | |
| 55283-6 | Fet Heart rate | |
| 8897-1 | QRS Complex nRate Hrt ventrs EKG | |
| 55284-4 | BP sys/dias | |
| 8478-0 | BP mean | |
| 8462-4 | BP dias | |
| 8480-6 | BP sys | |
| 8893-0 | Heart rate Periph a Palpation | |
| 44969-4 | Heart rate rhythm Palpation | |
| 8867-4 | Heart rate | |
| 9279-1 | Resp rate | |
| 8310-5 | Body temperature | |
| 29463-7 | Weight | |
| 3141-9 | Weight Measured | |
| 8302-2 | Body height | |
| 9269-2 | GCS total | |
| 9267-6 | GCS eye | |
| 9270-0 | GCS verbal | |
| 9268-4 | GCS motor | |
| 55285-1 | GCS special circumstances | |
| 55286-9 | Physical exam by body areas | |
| 10199-8 | Phys find Head | |
| 32432-7 | Phys find Face | |
| 32446-7 | Phys find Lip | |
| 32469-9 | Phys find Scalp | |
| 11411-6 | Phys find Neck | |
| 44965-2 | Jugular distention head up 30 deg | |
| 11391-0 | Phys find Chest | |
| 11392-8 | Phys find Chest wall | |
| 10193-1 | Phys find Brsts | |
| 11387-8 | Phys find Axilla | |
| 10200-4 | Phys find Hrt | |
| 10207-9 | Phys find Thorax+Lungs | |
| 10191-5 | Phys find Abd | |
| 11403-3 | Phys find Groin | |
| 10204-6 | Phys find Pelvis | |
| 11400-9 | Phys find Genitalia | |
| 11402-5 | Phys find Male genitalia | |
| 32465-7 | Phys find Prostate | |
| 11401-7 | Phys find Female genitalia | |
| 32487-1 | Phys find Vagina | |
| 32486-3 | Phys find Uterus | |
| 32423-6 | Phys find Cvx | |
| 11388-6 | Phys find Buttocks | |
| 10205-3 | Phys find Rectum | |
| 10192-3 | Phys find Back | |
| 32476-4 | Phys find Spine | |
| 32462-4 | Phys find Paravertebral muscles | |
| 11404-1 | Phys find Hand | |
| 32427-7 | Phys find Digits | |
| 56843-6 | Phys find Nail Bed | |
| 11415-7 | Phys find Wrist | |
| 11398-5 | Phys find Forearm | |
| 11394-4 | Phys find Elbow | |
| 11386-0 | Phys find Upper arm | |
| 11413-2 | Phys find Should | |
| 11397-7 | Phys find Ft | |
| 32480-6 | Phys find Toes | |
| 11385-2 | Phys find Ankle | |
| 11389-4 | Phys find Calf | |
| 11407-4 | Phys find Knee | |
| 11414-0 | Phys find Thigh | |
| 11406-6 | Phys find Hip | |
| 10197-2 | Phys find Eye | |
| 56844-4 | IOP Eye | |
| 32424-4 | Phys find Conjunctiva | |
| 32425-1 | Phys find Cornea | |
| 32429-3 | Phys find Extraocular muscles | |
| 32431-9 | Phys find Eye lid | |
| 32440-0 | Phys find Iris | |
| 32443-4 | Phys find Lacrimal apparatus | |
| 32459-0 | Phys find Optic lens | |
| 32466-5 | Phys find Pupil | |
| 32468-1 | Phys find Retina | |
| 32471-5 | Phys find Sclera | |
| 28631-0 | Visual acuity study | |
| 11393-6 | Phys find ENMT | |
| 10195-6 | Phys find Ear | |
| 32484-8 | Phys find Tympanic Memb | |
| 32421-0 | Phys find Auditory canal | |
| 10203-8 | Phys find Nose | |
| 32460-8 | Phys find Palate | |
| 32453-3 | Phys find Mouth | |
| 32478-0 | Phys find Teeth+gum | |
| 32483-0 | Phys find Tongue | |
| 56867-5 | Phys find Throat | |
| 32444-2 | Phys find Larynx | |
| 32482-2 | Phys find Tonsil | |
| 10201-2 | Phys find Mouth+Throat+Teeth | |
| 11390-2 | Phys find CVS | |
| 10208-7 | Phys find Vesl | |
| 56845-1 | Pulse strength on exam | |
| 11412-4 | Phys find Respiratory | |
| 11399-3 | Phys find GI | |
| 10198-0 | Phys find GU Tract | |
| 11410-8 | Phys find Musculoskeletal | |
| 32455-8 | Phys find Muscle tone | |
| 10206-1 | Phys find Skin | |
| 10202-0 | Phys find Neurologic | |
| 10190-7 | Mental status | |
| 56876-6 | Phys find Primitive reflexes | |
| 56873-3 | Phys find Brain stem reflexes | |
| 32473-1 | Phys find sensation | |
| 32452-5 | Phys find Motor function | |
| 10212-9 | Phys find Strength | |
| 10209-5 | Phys find Balance+Coordination | |
| 32433-5 | Phys find Gait | |
| 10194-9 | Phys find Deep tendon reflexes | |
| 32389-9 | DTR Achilles | |
| 32390-7 | DTR Biceps | |
| 32391-5 | DTR Brachioradialis | |
| 32392-3 | DTR Patella | |
| 32393-1 | DTR Triceps | |
| 32426-9 | Phys find Nerves.cranial | |
| 32385-7 | Babinski reflex | |
| 11451-2 | Psychiatric findings | |
| 11447-0 | Phys find Hem+Lymph+Immun | |
| 32450-9 | Phys find LN | |
| 29301-9 | Phys find Endocrine | |
| 32441-8 | Phys find Joint | |
| 8703-1 | Phys find Extremities | |
| 42348-3 | Adv healthcare directives | |