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
LOINC Copyright
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