LOINC
Version 2.68

10219-4Surgical operation note preoperative diagnosis NarrativeActive

Term Description

The Surgical operation note pre-operative diagnosis records the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.
Source: Regenstrief LOINC

Fully-Specified Name

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

Additional Names

Short Name
Operative note pre-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)
外科手术记录术前诊断:印象:时间点:^患者:叙述型:
nl-NLDutch (NETHERLANDS)
operatieverslag preoperatieve diagnose:interpretatie:moment:^patiënt:tekstueel:
fr-BEFrench (BELGIUM)
Note opération chirurgicale. Diagnostic préopératoire:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-ITItalian (ITALY)
Nota di operazione chirurgica, Dx preoperatoria:Imp:Pt:^Paziente:Nar:
ru-RURussian (RUSSIAN FEDERATION)
Хирургическая операция запись предоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
es-ARSpanish (ARGENTINA)
anotación quirúrgica: diagnóstico preoperatorio: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=10219-4