LOINC
Version 2.68

10218-6Surgical operation note postoperative diagnosis NarrativeActive

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
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.
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

zh-CNChinese (CHINA)
外科手术记录 术后诊断:印象:时间点:^患者:叙述型:
nl-NLDutch (NETHERLANDS)
operatieverslag postoperatieve diagnose:interpretatie:moment:^patiënt:tekstueel:
fr-BEFrench (BELGIUM)
Note opération chirurgicale. Diagnostic postopératoire:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-ITItalian (ITALY)
Nota di operazione chirurgica, Dx postoperatoria:Imp:Pt:^Paziente:Nar:
ru-RURussian (RUSSIAN FEDERATION)
Хирургическая операция запись послеоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
es-ARSpanish (ARGENTINA)
anotación quirúrgica: diagnóstico posoperatorio:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:

LOINC FHIR® API Example - CodeSystem Request Get Info

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