Version 2.78

Part Description

LP74249-1   Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure. Source: HL7

Fully-Specified Name

Component
Procedure note
Property
Find
Time
Pt
System
Outpatient
Scale
Doc
Method
{Role}

Additional Names

Short Name
OP Procedure note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.78
Last Updated
Version 2.78
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG41828-1 Outpatient|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38811-2 Procedure note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Procedura, nota:Osservazione:Pt:Paziente esterno:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Paziente ambulatoriale;Paziente non ricoverato Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) verslag ingreep:bevinding:moment:poliklinisch:document:{rol}
Synonyms: poli verslag procedure
zh-CN Chinese (China) 操作记录:发现:时间点:门诊病人:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 操作;程序;手续;步骤;规程;程序流程 操作项目记录 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书 门诊患者

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=104585-5