Version 2.78

Term Description

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.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Surgical operation note postoperative Dx
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Operative note post-op Dx

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) anotación quirúrgica: diagnóstico posoperatorio:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Nota operatoria postoperatoria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Note opération chirurgicale. Diagnostic postopératoire:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Nota di operazione chirurgica, Dx postoperatoria:Imp:Pt:^Paziente:Nar:
Synonyms: Diagnosi postoperatoria in nota di intervento chir Impressione/interpretazione di studio Nota di intervento chirurgico paziente Procedura chirurgica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag postoperatieve diagnose:interpretatie:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись послеоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Описательный Послеоперационный эпикриз Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录 术后诊断:印象:时间点:^患者:叙述型:
Synonyms: Dx 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 手术操作记录 术后诊断;外科手术操作记录 术后诊断;手术记录 术后诊断;外科手术记录 手术后诊断 手术操作记录;外科手术操作记录;手术记录 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书 诊断（Diagnosis，Dx）

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=10218-6