Version 2.78

Part Description

LP73465-4   Surgical operation note
Surgical operation note (Operative note) is note or report created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnoses, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report provides details to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care. Source: HL7

Fully-Specified Name

Component
Surgical operation note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Reproductive endocrinology and infertility

Additional Names

Short Name
REI Operative note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.74
Last Updated
Version 2.74
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG39092-8 Reproductive endocrinology and infertility|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38755-1 Surgical operation note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Nota di operazione chirurgica:Osservazione:Pt:{Setting}:Doc:Endocrinologia riproduttiva e infertilità
Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio)
zh-CN Chinese (China) 外科手术记录:发现:时间点:{环境}:文档型:生殖内分泌学和不孕
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 内分泌科;内分泌 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 手术操作记录;外科手术操作记录;手术记录 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 生殖内分泌学（内分泌科、内分泌）和不孕（不孕症）;生殖内分泌和不孕;生殖内分泌与不孕症 笔记;按语;注释;说明;票据;单据;证明书

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=101051-1