81244-6
Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
Active
Term Description
This panel contains the recommended sections for an enhanced procedure note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).
Source: Regenstrief LOINC
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81244-6 | Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections | |||
| Indent77599-9 | Additional documentation | R | ||
| Indent77598-1 | Externally defined clinical data elements Document | R | ||
| Indent77597-3 | Orders placed Document | R | ||
| Indent18776-5 | Plan of care note | R | ||
| Indent29762-2 | Social history Narrative | R | ||
| Indent48765-2 | Allergies | R | ||
| Indent59774-0 | Procedure anesthesia Narrative | R | ||
| Indent51847-2 | Evaluation + Plan note | R | ||
| Indent51848-0 | Evaluation note | R | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | R | ||
| Indent10154-3 | Chief complaint Narrative - Reported | R | ||
| Indent55109-3 | Complications Document | R | ||
| Indent10157-6 | History of family member diseases Narrative | R | ||
| Indent11348-0 | History of Past illness Narrative | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent11329-0 | History general Narrative - Reported | R | ||
| Indent46264-8 | History of medical device use | R | ||
| Indent29549-3 | Medication administered Narrative | R | ||
| Indent10160-0 | History of Medication use Narrative | R | ||
| Indent48768-6 | Payment sources Document | R | ||
| Indent29545-1 | Physical findings Narrative | R | ||
| Indent59772-4 | Planned procedure Narrative | R | ||
| Indent59769-0 | Postprocedure diagnosis Narrative | R | ||
| Indent29554-3 | Procedure Narrative | R | ||
| Indent59775-7 | Procedure disposition Narrative | R | ||
| Indent59770-8 | Procedure estimated blood loss Narrative | R | ||
| Indent59776-5 | Procedure findings Narrative | R | ||
| Indent59771-6 | Procedure implants Narrative | R | ||
| Indent59768-2 | Procedure indications [Interpretation] Narrative | R | ||
| Indent59773-2 | Procedure specimens taken Narrative | R | ||
| Indent47519-4 | History of Procedures Document | R | ||
| Indent29299-5 | Reason for visit Narrative | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R |
Fully-Specified Name
- Component
- Enhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections
- Property
- -
- Time
- Pt
- System
- {Setting}
- Scale
- -
- Method
Additional Names
- Short Name
- Encd Proced Nte CDP1 R1.0+R1.1
Basic Attributes
- Class
- PANEL.DOC
- Type
- Clinical
- First Released
- Version 2.56
- Last Updated
- Version 2.58
- Panel Type
- Convenience group
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de procedimiento mejorada: |
| it-IT | Italian (Italy) | Nota intervento arricchita-sezioni CDP Set 1 R1.0& R1.1 raccomandate: Synonyms: Nota di procedura Panel documentazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 增强型操作记录 - 推荐 CDP 集合 1 R1.0 与 R1.1 小节: Synonyms: Ⅰ I 事件发生的地方; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=81244-6 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/81244-6
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright