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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.

LOINC Names Get Info

Fully-Specified Name
Surgical operation note postoperative Dx:Imp:Pt:^Patient:Nar:
Long Common Name
Surgical operation note postoperative diagnosis Narrative
Short Name
Operative note post-op Dx

Part Model Get Info

  • Component
    Surgical operation note postoperative Dx
    LP73476-1
    • Analyte
      Surgical operation note postoperative Dx
      LP73476-1
      • Component Numerator
        Surgical operation note postoperative Dx
        LP73476-1
        • Component Numerator Core
          Surgical operation note postoperative Dx
          LP73476-1
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Imp
    LP6819-9
  • Time
    Pt
    LP6960-1
  • System
    ^Patient
    LP310005-6
    • System Core
      NULL
       
    • Super System
      Patient
      LP6985-8
  • Scale
    Nar
    LP7749-7
  • Method
    NULL
     

Basic Attributes

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

Member of these Panels

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

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Σημείωμα χειρουργικής επέμβασης: μετεγχειρητική διάγνωση:Imp:Pt:^Ασθενής:Nar:
Synonyms: - H&P.SURG PROC Imp Nar Pt SURG Ασθενής Σημείωμα χειρουργικής επέμβασης Σημείωμα χειρουργικής επέμβασης: μετεγχειρητική διάγνωση Σημείωση
es-ARSpanish (Argentina)anotación quirúrgica: diagnóstico posoperatorio:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:
es-MXSpanish (Mexico)Nota operatoria postoperatoria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:
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:
Synonyms: Diagnosi postoperatoria in nota di intervento chir Impressione/interpretazione di studio Nota di intervento chirurgico paziente Procedura chirurgica Punto nel tempo (episodio)
nl-NLDutch (Netherlands)operatieverslag postoperatieve diagnose:interpretatie:moment:^patiënt:tekstueel:
ru-RURussian (Russian Federation)Хирургическая операция запись послеоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Описательный Послеоперационный эпикриз Точка во времени;Момент
zh-CNChinese (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