72227-2  Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:  

PANEL HIERARCHY  (view this panel in the LForms viewer)

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:    
       59774-0   Procedure anesthesia NarrativeProcedure anesthesia NarrativeProcedure anesthesia: Find: Pt: ^Patient: Nar: R    
       55109-3   Complications DocumentComplications DocumentComplications: Find: Pt: ^Patient: Doc: R    
       10218-6   Surgical operation note postoperative diagnosis NarrativeSurgical operation note postoperative diagnosis NarrativeSurgical operation note postoperative Dx: Imp: Pt: ^Patient: Nar: R    
       10219-4   Surgical operation note preoperative diagnosis NarrativeSurgical operation note preoperative diagnosis NarrativeSurgical operation note preoperative Dx: Imp: Pt: ^Patient: Nar: R    
       59770-8   Procedure estimated blood loss NarrativeProcedure estimated blood loss NarrativeProcedure estimated blood loss: Find: Pt: ^Patient: Nar: R    
       59776-5   Procedure findings NarrativeProcedure findings NarrativeProcedure findings: Find: Pt: ^Patient: Nar: R    
       59773-2   Procedure specimens taken NarrativeProcedure specimens taken NarrativeProcedure specimens taken: Find: Pt: ^Patient: Nar: R    
       29554-3   Procedure NarrativeProcedure NarrativeProcedure: Type: Pt: ^Patient: Nar: R    
       59771-6   Procedure implants NarrativeProcedure implants NarrativeProcedure implants: Find: Pt: ^Patient: Nar: O    
       10216-0   Surgical operation note fluids NarrativeSurgical operation note fluids NarrativeSurgical operation note fluids: Type: Pt: ^Patient: Nar: O    
       10223-6   Surgical operation note surgical procedure NarrativeSurgical operation note surgical procedure NarrativeSurgical operation note surgical procedure: Find: Pt: ^Patient: Nar: O    
       18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role} O    
       59772-4   Planned procedure NarrativePlanned procedure NarrativePlanned procedure: Find: Pt: ^Patient: Nar: O    
       59775-7   Procedure disposition NarrativeProcedure disposition NarrativeProcedure disposition: Find: Pt: ^Patient: Nar: O    
       59768-2   Procedure indications [Interpretation] NarrativeProcedure indications [Interpretation] NarrativeProcedure indications: Imp: Pt: ^Patient: Nar: O    
       11537-8   Surgical drains NarrativeSurgical drains NarrativeSurgical drains: Find: Pt: Surgical procedure: Nar: O    
 

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections  Pt  {Setting} 
  Long Common Name:  Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  Shortname:  Surg Op C-CDA R1.1+2.0+2.1 Sections

TERM DEFINITION/DESCRIPTION(S)
  This panel contains the recommended sections for surgical operation notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.
 
 

BASIC ATTRIBUTES
  Class/Type: PANEL.DOC/Clinical
  Panel Type: Convenience group
  First Released in Version: 2.42
  Last Updated in Version: 2.56
  Status: Active.
Change Reason: Changed Component name to reflect that this convenience panel contains recommended sections for C-CDA Release 1.1, 2.0 and 2.1.

PARTS

Part Type    Part No.  Part Name   
Component   LP157178-7  Surgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections   [Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections] 
Property   LP6769-6 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP7747-1 
Fragments for synonyms   LP20143-1  CDA 
Fragments for synonyms   LP100628-9  Surgical 
Fragments for synonyms   LP183649-5  note 
Fragments for synonyms   LP21059-8  Panel 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外科手术记录 - 推荐 CDA 小节:-:时间点:{环境}:-:外科手术记录 - 推荐 CDA 小节:-:时间点:{环境}:-:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Nota di operazione chirurgica - sezioni C-CDA R1.1 &R2.0 & R2.1 raccomandati:-:Pt:{Setting}:-:Nota di operazione chirurgica - sezioni C-CDA R1.1 &R2.0 & R2.1 raccomandati:-:Pt:{Setting}:-:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Хирургическая операция запись - рекомендованные CDA разделы:-:ТчкВрм:{Окружение}:-:Хирургическая операция запись - рекомендованные CDA разделы:-:ТчкВрм:{Окружение}:-:

RELATED NAMES
  Congenital dyserythropoietic anaemia Pan Random
  Encounter Panel Surg
  Evaluation and management PANEL.DOC Surg Op C-CDA R1.1+2.0+2.1 Sections
  Evaluation and management note Panl Visit note
  notes Pnl  
  Operative note Point in time  

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:17 PM
  Long Common Name: Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
  Shortname: Surg Op C-CDA R1.1+2.0+2.1 Sections
  Fully Specified Name: Surgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
     
  Component Word Count: 10
  ID: 71627
  # of Panel Elements: 17
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



59774-0   Procedure anesthesia NarrativeProcedure anesthesia NarrativeProcedure anesthesia: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure anesthesia  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure anesthesia Narrative
  Shortname:  Anesthesia

TERM DEFINITION/DESCRIPTION(S)
  The Anesthesia section briefly records the type of anesthesia (e.g., general, conscious, or local) and may state the actual agent(s) used.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100694-1  Procedure anesthesia 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作麻醉:发现:时间点:^患者:叙述型:操作麻醉:发现:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura anestesia:Osservazione:Pt:^Paziente:Nar:Procedura anestesia:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство анестезия:Находка:ТчкВрм:^Пациент:Опис:Вмешательство анестезия:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:17 PM
  Attachment Units Required: N
  Long Common Name: Procedure anesthesia Narrative
  Shortname: Anesthesia
  Fully Specified Name: Procedure anesthesia: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54681
  Status (Raw): ACTIVE


55109-3   Complications DocumentComplications DocumentComplications: Find: Pt: ^Patient: Doc:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Complications  Find  Pt  ^Patient  Doc 
  Long Common Name:  Complications Document
  Shortname:  Complications Doc

TERM DEFINITION/DESCRIPTION(S)
  Information on additional medical problems that develop following a procedure, diagnostic test or study, treatment, or illness.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  62863-6   PhenX domain - Infectious diseases and immunityPhenX domain - Infectious diseases and immunityPhenX domain - Infectious diseases and immunity: -: Pt: ^Patient: -: PhenX
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72230-6   Diagnostic imaging report - recommended C-CDA R1.1 sectionsDiagnostic imaging report - recommended C-CDA R1.1 sectionsDiagnostic imaging report - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81220-6   Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sectionsDiagnostic imaging report - recommended C-CDA R2.0 and R2.1 sectionsDiagnostic imaging report - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  87416-4   Diagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP72306-1  Complications 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP32888-7  Doc 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  并发症:发现:时间点:^患者:文档型:并发症:发现:时间点:^患者:文档型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Complicazioni:Osservazione:Pt:^Paziente:Doc:Complicazioni:Osservazione:Pt:^Paziente:Doc:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Осложнения:Находка:ТчкВрм:^Пациент:Док:Осложнения:Находка:ТчкВрм:^Пациент:Док:

RELATED NAMES
  DOC.MISC Findings Random
  Document MISC  
  Finding Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:18 PM
  Attachment Units Required: N
  Long Common Name: Complications Document
  Shortname: Complications Doc
  Fully Specified Name: Complications: Find: Pt: ^Patient: Doc:
     
  Component Word Count: 1
  ID: 49468
  Status (Raw): ACTIVE


10218-6   Surgical operation note postoperative diagnosis NarrativeSurgical operation note postoperative diagnosis NarrativeSurgical operation note postoperative Dx: Imp: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical operation note postoperative Dx  Imp  Pt  ^Patient  Nar 
  Long Common Name:  Surgical operation note postoperative diagnosis Narrative
  Shortname:  Operative note post-op Dx

TERM DEFINITION/DESCRIPTION(S)
  The Surgical operation note postoperative diagnosis records the diagnosis or diagnoses discovered or confirmed during the surgery. Often it is the same as the pre-operative diagnosis.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: H&P.SURG PROC/Clinical
  First Released in Version: 1.0i
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59270-9   Surgical operative note panelSurgical operative note panelSurgical operative note panel: -: Pt: ^Patient: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73476-1  Surgical operation note postoperative Dx   [Surgical operation note postoperative diagnosis] 
Property   LP6819-9  Imp   [Impression/interpretation of study] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP100628-9  Surgical 
Fragments for synonyms   LP183649-5  note 
Fragments for synonyms   LP30831-9  Dx 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外科手术记录 术后诊断:印象:时间点:^患者:叙述型:外科手术记录 术后诊断:印象:时间点:^患者:叙述型:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Note opération chirurgicale. Diagnostic postopératoire:Impression/​interprétation d'étude:Temps ponctuel:^Patient:Narratif:Note opération chirurgicale. Diagnostic postopératoire:Impression/​interprétation d'étude:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Nota di operazione chirurgica, Dx postoperatoria:Imp:Pt:^Paziente:Nar:Nota di operazione chirurgica, Dx postoperatoria:Imp:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Хирургическая операция запись послеоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:Хирургическая операция запись послеоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  anotación quirúrgica: diagnóstico posoperatorio:impresión/​interpretación del estudio:punto en el tiempo:^paciente:Narrativo:anotación quirúrgica: diagnóstico posoperatorio:impresión/​interpretación del estudio:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Diagnosis Impressions Point in time
  Encounter Interp Random
  Evaluation and management Interpretation Report
  Evaluation and management note Narrative Surg
  H+P notes Visit note
  H+P.SURGICAL PROCEDURES Operative note  
  Impression Operative note post-op Dx  
  Impression/interpretation of study P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:18 PM
  Long Common Name: Surgical operation note postoperative diagnosis Narrative
  Shortname: Operative note post-op Dx
  Fully Specified Name: Surgical operation note postoperative Dx: Imp: Pt: ^Patient: Nar:
     
  Component Word Count: 5
  ID: 271
  Status (Raw): ACTIVE


10219-4   Surgical operation note preoperative diagnosis NarrativeSurgical operation note preoperative diagnosis NarrativeSurgical operation note preoperative Dx: Imp: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical operation note preoperative Dx  Imp  Pt  ^Patient  Nar 
  Long Common Name:  Surgical operation note preoperative diagnosis Narrative
  Shortname:  Operative note pre-op Dx

TERM DEFINITION/DESCRIPTION(S)
  The Surgical operation note pre-operative diagnosis records the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: H&P.SURG PROC/Clinical
  First Released in Version: 1.0i
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59270-9   Surgical operative note panelSurgical operative note panelSurgical operative note panel: -: Pt: ^Patient: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73477-9  Surgical operation note preoperative Dx   [Surgical operation note preoperative diagnosis] 
Property   LP6819-9  Imp   [Impression/interpretation of study] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP30831-9  Dx 
Fragments for synonyms   LP100628-9  Surgical 
Fragments for synonyms   LP183649-5  note 
Fragments for synonyms   LP91296-1  Preoperative 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外科手术记录术前诊断:印象:时间点:^患者:叙述型:外科手术记录术前诊断:印象:时间点:^患者:叙述型:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Note opération chirurgicale. Diagnostic préopératoire:Impression/​interprétation d'étude:Temps ponctuel:^Patient:Narratif:Note opération chirurgicale. Diagnostic préopératoire:Impression/​interprétation d'étude:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Nota di operazione chirurgica, Dx preoperatoria:Imp:Pt:^Paziente:Nar:Nota di operazione chirurgica, Dx preoperatoria:Imp:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Хирургическая операция запись предоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:Хирургическая операция запись предоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  anotación quirúrgica: diagnóstico preoperatorio:impresión/​interpretación del estudio:punto en el tiempo:^paciente:Narrativo:anotación quirúrgica: diagnóstico preoperatorio:impresión/​interpretación del estudio:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Diagnosis Impressions Point in time
  Encounter Interp Pre-Op
  Evaluation and management Interpretation Random
  Evaluation and management note Narrative Report
  H+P notes Surg
  H+P.SURGICAL PROCEDURES Operative note Visit note
  Impression Operative note pre-op Dx  
  Impression/interpretation of study P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:18 PM
  Long Common Name: Surgical operation note preoperative diagnosis Narrative
  Shortname: Operative note pre-op Dx
  Fully Specified Name: Surgical operation note preoperative Dx: Imp: Pt: ^Patient: Nar:
     
  Component Word Count: 5
  ID: 272
  Status (Raw): ACTIVE


59770-8   Procedure estimated blood loss NarrativeProcedure estimated blood loss NarrativeProcedure estimated blood loss: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure estimated blood loss  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure estimated blood loss Narrative
  Shortname:  Estimated blood loss

TERM DEFINITION/DESCRIPTION(S)
  Procedure estimated blood loss is the approximate amount of blood that the patient lost during the procedure or surgery. It may be an accurate quantitative amount, e.g., 250 milliliters, or it may be descriptive, e.g., "minimal" or "none".
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100690-9  Procedure estimated blood loss 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP76273-9  Blood loss 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作预计失血量:发现:时间点:^患者:叙述型:操作预计失血量:发现:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:Procedura, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:Вмешательство предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  Bld loss Findings Random
  Blood output MISC Report
  DOC.MISC Narrative  
  Finding Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:19 PM
  Attachment Units Required: N
  Long Common Name: Procedure estimated blood loss Narrative
  Shortname: Estimated blood loss
  Fully Specified Name: Procedure estimated blood loss: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 4
  ID: 54676
  Status (Raw): ACTIVE


59776-5   Procedure findings NarrativeProcedure findings NarrativeProcedure findings: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure findings  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure findings Narrative
  Shortname:  Findings

TERM DEFINITION/DESCRIPTION(S)
  The Procedure findings section records clinically significant observations confirmed or discovered during a procedure, treatment or service.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  87416-4   Diagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100696-6  Procedure findings 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作发现:发现:时间点:^患者:叙述型:操作发现:发现:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura, osservazioni:Osservazione:Pt:^Paziente:Nar:Procedura, osservazioni:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство находки:Находка:ТчкВрм:^Пациент:Опис:Вмешательство находки:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:19 PM
  Attachment Units Required: N
  Long Common Name: Procedure findings Narrative
  Shortname: Findings
  Fully Specified Name: Procedure findings: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54683
  Status (Raw): ACTIVE


59773-2   Procedure specimens taken NarrativeProcedure specimens taken NarrativeProcedure specimens taken: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure specimens taken  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure specimens taken Narrative
  Shortname:  Specimens taken

TERM DEFINITION/DESCRIPTION(S)
  The Procedure specimens taken section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis. The narrative may include a description of the specimens.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100693-3  Procedure specimens taken 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  已采集的操作标本:发现:时间点:^患者:叙述型:已采集的操作标本:发现:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura, campioni prelevati:Osservazione:Pt:^Paziente:Nar:Procedura, campioni prelevati:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство образцы изъятые:Находка:ТчкВрм:^Пациент:Опис:Вмешательство образцы изъятые:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:19 PM
  Attachment Units Required: N
  Long Common Name: Procedure specimens taken Narrative
  Shortname: Specimens taken
  Fully Specified Name: Procedure specimens taken: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 3
  ID: 54679
  Status (Raw): ACTIVE


29554-3   Procedure NarrativeProcedure NarrativeProcedure: Type: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure  Type  Pt  ^Patient  Nar 
  Long Common Name:  Procedure Narrative
  Shortname:  Procedure

TERM DEFINITION/DESCRIPTION(S)
  Procedure records the descriptions of the procedure with an extensive narrative and may include procedure site preparation, pertinent details related to measurements and markings, procedure times, instrumentation, and vital signs and other monitoring data.
 
 

OBSERVATION REQUIRED IN PANEL
Required

BASIC ATTRIBUTES
  Class/Type: H&P.PX/Clinical
  First Released in Version: 2.03
  Last Updated in Version: 2.40
  Status: Active

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  82315-3   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sectionsLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 sectionsLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 sections: -: Pt: {Setting}: -:
  84429-0   Level 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 and R2 setLevel 3 emergency medical services patient care report - recommended CDA R1 & R2 set: -: Pt: {Setting}: -:
  84907-5   Cancer pathology panel - Colorectal cancer specimenCancer pathology panel - Colorectal cancer specimenCancer pathology panel: -: Pt: Colorectal cancer specimen: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73191-6  Procedure 
Property   LP6886-8  Type 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作项目:类型:时间点:^患者:叙述型:操作项目:类型:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura:Tipo:Pt:^Paziente:Nar:Procedura:Tipo:Pt:^Paziente:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Procedimento:Tipo:Pt:^Paciente:Nar:Procedimento:Tipo:Pt:^Paciente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство:Тип:ТчкВрм:^Пациент:Опис:Вмешательство:Тип:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  procedimiento:tipo:punto en el tiempo:^paciente:Narrativo:procedimiento:tipo:punto en el tiempo:^paciente:Narrativo:
  Spanish (SPAIN)  (From: Regenstrief-generated full translation based on part translation provided by the Clinical Laboratory Committee of SERVICIO EXTREMEÑO DE SALUD, with the support of BITAC MAP.)
 
  Procedimiento:Tipo:Punto temporal:^paciente:Narrativo:Procedimiento:Tipo:Punto temporal:^paciente:Narrativo:

RELATED NAMES
  H+P P prime Report
  H+P.PX Point in time Typ
  Narrative Random  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:19 PM
  Attachment Units Required: N
  Long Common Name: Procedure Narrative
  Shortname: Procedure
  Fully Specified Name: Procedure: Type: Pt: ^Patient: Nar:
     
  Component Word Count: 1
  ID: 21335
  Status (Raw): ACTIVE


59771-6   Procedure implants NarrativeProcedure implants NarrativeProcedure implants: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure implants  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure implants Narrative
  Shortname:  Implants

TERM DEFINITION/DESCRIPTION(S)
  The Procedure implants section records any materials placed during a procedure including stents, tubes, and drains.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100691-7  Procedure implants 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作植入物:发现:时间点:^患者:叙述型:操作植入物:发现:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura impianti:Osservazione:Pt:^Paziente:Nar:Procedura impianti:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство импланты:Находка:ТчкВрм:^Пациент:Опис:Вмешательство импланты:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:20 PM
  Attachment Units Required: N
  Long Common Name: Procedure implants Narrative
  Shortname: Implants
  Fully Specified Name: Procedure implants: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54677
  Status (Raw): ACTIVE


10216-0   Surgical operation note fluids NarrativeSurgical operation note fluids NarrativeSurgical operation note fluids: Type: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical operation note fluids  Type  Pt  ^Patient  Nar 
  Long Common Name:  Surgical operation note fluids Narrative
  Shortname:  Operative note fluids

TERM DEFINITION/DESCRIPTION(S)
  A record of fluids administered during the surgical procedure.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: H&P.SURG PROC/Clinical
  First Released in Version: 1.0i
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59270-9   Surgical operative note panelSurgical operative note panelSurgical operative note panel: -: Pt: ^Patient: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73473-8  Surgical operation note fluids 
Property   LP6886-8  Type 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP100628-9  Surgical 
Fragments for synonyms   LP183649-5  note 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外科手术记录 液体:类型:时间点:^患者:叙述型:外科手术记录 液体:类型:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Nota di operazione chirurgica, liquidi:Tipo:Pt:^Paziente:Nar:Nota di operazione chirurgica, liquidi:Tipo:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Хирургическая операция запись жидкости:Тип:ТчкВрм:^Пациент:Опис:Хирургическая операция запись жидкости:Тип:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  anotación quirúrgica: líquidos:tipo:punto en el tiempo:^paciente:Narrativo:anotación quirúrgica: líquidos:tipo:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Encounter notes Report
  Evaluation and management Operative note Surg
  Evaluation and management note Operative note fluids Typ
  H+P P prime Visit note
  H+P.SURGICAL PROCEDURES Point in time  
  Narrative Random  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:20 PM
  Long Common Name: Surgical operation note fluids Narrative
  Shortname: Operative note fluids
  Fully Specified Name: Surgical operation note fluids: Type: Pt: ^Patient: Nar:
     
  Component Word Count: 4
  ID: 269
  Status (Raw): ACTIVE


10223-6   Surgical operation note surgical procedure NarrativeSurgical operation note surgical procedure NarrativeSurgical operation note surgical procedure: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical operation note surgical procedure  Find  Pt  ^Patient  Nar 
  Long Common Name:  Surgical operation note surgical procedure Narrative
  Shortname:  Operative note procedure

TERM DEFINITION/DESCRIPTION(S)
  This term may be used to restate the procedures performed, if appropriate, for an enterprise workflow. The procedure(s) performed associated with the Operative note are formally modeled in the header using serviceEvent.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: H&P.SURG PROC/Clinical
  First Released in Version: 1.0i
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59270-9   Surgical operative note panelSurgical operative note panelSurgical operative note panel: -: Pt: ^Patient: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73482-9  Surgical operation note surgical procedure 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP100628-9  Surgical 
Fragments for synonyms   LP183649-5  note 
Fragments for synonyms   LP75922-2  P' 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外科手术记录 外科手术操作:发现:时间点:^患者:叙述型:外科手术记录 外科手术操作:发现:时间点:^患者:叙述型:
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Note opération chirurgicale. Procédures chirurgicales:Observation:Temps ponctuel:^Patient:Narratif:Note opération chirurgicale. Procédures chirurgicales:Observation:Temps ponctuel:^Patient:Narratif:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Nota di operazione chirurgica, procedura chirurgica:Osservazione:Pt:^Paziente:Nar:Nota di operazione chirurgica, procedura chirurgica:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Хирургическая операция запись хирургическое вмешательство:Находка:ТчкВрм:^Пациент:Опис:Хирургическая операция запись хирургическое вмешательство:Находка:ТчкВрм:^Пациент:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  anotación quirúrgica: procedimiento quirúrgico:hallazgo:punto en el tiempo:^paciente:Narrativo:anotación quirúrgica: procedimiento quirúrgico:hallazgo:punto en el tiempo:^paciente:Narrativo:

RELATED NAMES
  Encounter H+P.SURGICAL PROCEDURES Point in time
  Evaluation and management Narrative Random
  Evaluation and management note notes Report
  Finding Operative note Surg
  Findings Operative note procedure Visit note
  H+P P prime  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:20 PM
  Long Common Name: Surgical operation note surgical procedure Narrative
  Shortname: Operative note procedure
  Fully Specified Name: Surgical operation note surgical procedure: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 5
  ID: 277
  Status (Raw): ACTIVE


18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role}  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Plan of care note  Find  Pt  {Setting}  Doc  {Role}
  Long Common Name:  Plan of care note
  Shortname:  Plan of care note

TERM DEFINITION/DESCRIPTION(S)
  Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 1.0l
  Last Updated in Version: 2.63
  HL7 Attachment Structure: IG exists
  Status: Active.
Change Reason: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.; 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.

ASSOCIATED OBSERVATIONS

Definition/Description: This panel contains the recommended sections for a care plan note based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81215-6   Care plan - recommended C-CDA R2.0 and R2.1 sectionsCare plan - recommended C-CDA R2.0 and R2.1 sectionsCare plan - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:    
       61146-7   Goals NarrativeGoals NarrativeGoals: Find: Pt: ^Patient: Nar: R    
       75310-3   Health concerns DocumentHealth concerns DocumentHealth concerns: Find: Pt: ^Patient: Doc: R    
       11383-7   Patient problem outcome NarrativePatient problem outcome NarrativePatient problem outcome: Find: Pt: ^Patient: Nar: O    
       62387-6   Interventions NarrativeInterventions NarrativeInterventions: Find: Pt: ^Patient: Nar: O    
 

MEMBER OF THESE PANELS
  48769-4   Continuity of Care panelContinuity of Care panelContinuity of Care panel: -: Pt: ^Patient: -:
  57082-0   Antepartum record panelAntepartum record panelAntepartum record panel: -: Pt: ^Patient: -:
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  69459-6   Care record summary panelCare record summary panelCare record summary panel: -: Pt: ^Patient: -:
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72228-0   History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsHistory and physical note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  72229-8   Discharge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sectionsDischarge summary - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72232-2   Continuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sectionsContinuity of Care Document - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  74293-2   Oncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA setOncology plan of care and summary - recommended CDA set: -: Pt: {Setting}: -:
  74449-0   Patient plan of care - recommended IHE setPatient plan of care - recommended IHE setPatient plan of care - recommended IHE set: -: Pt: {Setting}: -:
  81214-9   Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 and R2.1 sectionsContinuity of Care Document - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81218-0   Discharge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sectionsDischarge summary - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81219-8   Discharge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sectionsDischarge summary - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81221-4   Transfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sectionsTransfer summary note - recommended C-CDA R2.0 sections: -: Pt: {Setting}: -:
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81223-0   Referral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 and R2.1 sectionsReferral note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81242-0   Enhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.0 sections: -: Pt: {Setting}: -:
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81614-0   Transfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sectionsTransfer summary note - recommended C-CDA R2.1 sections: -: Pt: {Setting}: -:
  81615-7   Enhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sectionsEnhanced discharge summary - recommended CDP Set 1 R1.1 sections: -: Pt: {Setting}: -:
  82308-8   Oncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sectionsOncology plan of care and summary - recommended CDA R1.2 sections: -: Pt: {Setting}: -:
  82811-1   Nurse summary note - recommended sectionsNurse summary note - recommended sectionsNurse summary note - recommended sections: -: Pt: {Setting}: -:

MEMBER OF THESE EQUIVALENCE GROUPS
  LG38745-2  Plan of care note|ANYRole|ANYSetting
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP157909-5  Plan of care note 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP187178-1  {Role}   [Role-unspecified] 
Fragments for synonyms   LP183649-5  note 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  医疗服务计划记录:发现:时间点:{环境}:文档型:{角色}医疗服务计划记录:发现:时间点:{环境}:文档型:{角色}
  German (GERMANY)  (From: Institute for Medical Documentation and Information (DIMDI))
 
  Behandlungsplan:Bef:Pkt:Behandlungsplan:Nar:Behandlungsplan:Bef:Pkt:Behandlungsplan:Nar:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:{Role}Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:{Role}
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  plan de tratamiento:hallazgo:punto en el tiempo:plan de tratamiento:Narrativo:plan de tratamiento:hallazgo:punto en el tiempo:plan de tratamiento:Narrativo:

RELATED NAMES
  Care plan Evaluation and management note Random
  DOC.ONT Finding Treatment plan
  Document Findings Visit note
  Encounter notes  
  Evaluation and management Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:21 PM
  Long Common Name: Plan of care note
  Shortname: Plan of care note
  Fully Specified Name: Plan of care note: Find: Pt: {Setting}: Doc: {Role}
     
  Component Word Count: 4
  ID: 9693
  # of Panel Elements: 5
  Status (Raw): ACTIVE


59772-4   Planned procedure NarrativePlanned procedure NarrativePlanned procedure: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Planned procedure  Find  Pt  ^Patient  Nar 
  Long Common Name:  Planned procedure Narrative
  Shortname:  Planned procedure

TERM DEFINITION/DESCRIPTION(S)
  The Planned Procedure section records the procedure(s) that the clinician thought would be needed based on the pre-procedure assessment.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100692-5  Planned procedure 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  所计划的操作:发现:时间点:^患者:叙述型:所计划的操作:发现:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura prevista:Osservazione:Pt:^Paziente:Nar:Procedura prevista:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Запланированное вмешательство:Находка:ТчкВрм:^Пациент:Опис:Запланированное вмешательство:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:21 PM
  Attachment Units Required: N
  Long Common Name: Planned procedure Narrative
  Shortname: Planned procedure
  Fully Specified Name: Planned procedure: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54678
  Status (Raw): ACTIVE


59775-7   Procedure disposition NarrativeProcedure disposition NarrativeProcedure disposition: Find: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure disposition  Find  Pt  ^Patient  Nar 
  Long Common Name:  Procedure disposition Narrative
  Shortname:  Disposition

TERM DEFINITION/DESCRIPTION(S)
  The Procedure disposition section records the status and condition of the patient at the completion of the procedure or surgery. It often also states where the patent was transferred to for the next level of care.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100695-8  Procedure disposition 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作处置:发现:时间点:^患者:叙述型:操作处置:发现:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura, disposizione:Osservazione:Pt:^Paziente:Nar:Procedura, disposizione:Osservazione:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство диспозиция:Находка:ТчкВрм:^Пациент:Опис:Вмешательство диспозиция:Находка:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC MISC Random
  Finding Narrative Report
  Findings Point in time  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:21 PM
  Attachment Units Required: N
  Long Common Name: Procedure disposition Narrative
  Shortname: Disposition
  Fully Specified Name: Procedure disposition: Find: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54682
  Status (Raw): ACTIVE


59768-2   Procedure indications [Interpretation] NarrativeProcedure indications [Interpretation] NarrativeProcedure indications: Imp: Pt: ^Patient: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Procedure indications  Imp  Pt  ^Patient  Nar 
  Long Common Name:  Procedure indications [Interpretation] Narrative
  Shortname:  Procedure indications Imp

TERM DEFINITION/DESCRIPTION(S)
  The Procedure indications section records details about the reason for the procedure, treatment or service.
 
 

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: DOC.MISC/Clinical
  First Released in Version: 2.32
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  59843-3   Procedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sectionsProcedure note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81217-2   Procedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 and R2.1 sectionsProcedure note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81244-6   Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced procedure note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  87416-4   Diagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sectionsDiagnostic imaging report - recommended DICOM PS3.20 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP100852-5  Procedure indications 
Property   LP6819-9  Imp   [Impression/interpretation of study] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7749-7  Nar 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  操作适应症:印象:时间点:^患者:叙述型:操作适应症:印象:时间点:^患者:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Procedura, indicazioni:Imp:Pt:^Paziente:Nar:Procedura, indicazioni:Imp:Pt:^Paziente:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Вмешательство показания:Впчт:ТчкВрм:^Пациент:Опис:Вмешательство показания:Впчт:ТчкВрм:^Пациент:Опис:

RELATED NAMES
  DOC.MISC Interp Point in time
  Impression Interpretation Random
  Impression/interpretation of study MISC Report
  Impressions Narrative  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:22 PM
  Attachment Units Required: N
  Long Common Name: Procedure indications [Interpretation] Narrative
  Shortname: Procedure indications Imp
  Fully Specified Name: Procedure indications: Imp: Pt: ^Patient: Nar:
     
  Component Word Count: 2
  ID: 54674
  Status (Raw): ACTIVE


11537-8   Surgical drains NarrativeSurgical drains NarrativeSurgical drains: Find: Pt: Surgical procedure: Nar:  

NAME
  Fully-Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical drains  Find  Pt  Surgical procedure  Nar 
  Long Common Name:  Surgical drains Narrative
  Shortname:  Surgical drains

OBSERVATION REQUIRED IN PANEL
Optional

BASIC ATTRIBUTES
  Class/Type: CLIN/Clinical
  First Released in Version: 1.0j-a
  Last Updated in Version: 2.63
  Status: Active.
Change Reason: 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.

MEMBER OF THESE PANELS
  72227-2   Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sectionsSurgical operation note - recommended C-CDA R1.1 & R2.0 & R2.1 sections: -: Pt: {Setting}: -:
  81241-2   Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sectionsEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:
  81245-3   Interval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 and R1.1 sectionsInterval document - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:

PARTS

Part Type    Part No.  Part Name   
Component   LP73457-1  Surgical drains 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP7616-8  Surgical procedure   [Surgery] 
Scale   LP7749-7  Nar 
Fragments for synonyms   LP100628-9  Surgical 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  外科手术引流:发现:时间点:外科手术操作:叙述型:外科手术引流:发现:时间点:外科手术操作:叙述型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Drenaggio chirurgico:Osservazione:Pt:Procedura chirurgica:Nar:Drenaggio chirurgico:Osservazione:Pt:Procedura chirurgica:Nar:
  Portuguese (BRAZIL)  (From: HL7 Brazil Institute)
 
  Drenos cirúrgicos:Achado:Pt:Procedimento cirurgico:Nar:Drenos cirúrgicos:Achado:Pt:Procedimento cirurgico:Nar:
  Russian (RUSSIAN FEDERATION)  (From: Regenstrief-generated full translation based on part translation provided by Yaroslavl State Medical Academy)
 
  Хирургические дренажи:Находка:ТчкВрм:Хирургическое вмешательство:Опис:Хирургические дренажи:Находка:ТчкВрм:Хирургическое вмешательство:Опис:
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  drenajes quirúrgicos:hallazgo:punto en el tiempo:procedimiento quirúrgico:Narrativo:drenajes quirúrgicos:hallazgo:punto en el tiempo:procedimiento quirúrgico:Narrativo:

RELATED NAMES
  CLIN Narrative Report
  Finding Point in time Surg
  Findings Random  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 12/12/2018 8:41:22 PM
  Long Common Name: Surgical drains Narrative
  Shortname: Surgical drains
  Fully Specified Name: Surgical drains: Find: Pt: Surgical procedure: Nar:
     
  Component Word Count: 2
  ID: 1708
  Status (Raw): ACTIVE