11488-4Consult noteActive
Part Description
LP72311-1 Consultation note
A consultation note is generated by a provider upon request for an opinion or advice from another provider. Consultations may involve face-to-face time with the patient, telemedicine visits, or a second opinion on a diagnosis that does not involve interaction with a patient. A consultation note is typically sent to the referring provider when the consultation is completed.
Source: Regenstrief LOINC
Fully-Specified Name
- Component
- Consultation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Consult note
Associated Observations
This panel contains the recommended sections for consultation notes based on HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81222-2 | Consultation note - recommended C-CDA R2.0 and R2.1 sections | |||
| Indent51847-2 | Assessment+Plan | R | ||
| Indent51848-0 | Assessment | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent11348-0 | Past medical history | R | ||
| Indent29545-1 | Physical examination | R | ||
| Indent29299-5 | Reason for visit | R | ||
| Indent42348-3 | Advance directives | O | ||
| Indent48765-2 | Allergies | O | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | O | ||
| Indent10154-3 | Chief complaint Narrative - Reported | O | ||
| Indent10157-6 | Family history | O | ||
| Indent47420-5 | Functional status assessment note | O | ||
| Indent10210-3 | General status | O | ||
| Indent10164-2 | History of Present illness Narrative | O | ||
| Indent11369-6 | History of immunizations | O | ||
| Indent46264-8 | History of medical device use | O | ||
| Indent10160-0 | Medications | O | ||
| Indent10190-7 | Mental status Narrative | O | ||
| Indent61144-2 | Diet and nutrition Narrative | O | ||
| Indent11450-4 | Problems | O | ||
| Indent47519-4 | Procedures | O | ||
| Indent30954-2 | Results | O | ||
| Indent10187-3 | Review of systems | O | ||
| Indent29762-2 | Social history | O | ||
| Indent8716-3 | Vital signs | O |
Associated Observations
This panel contains the recommended sections for consultation notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 72231-4 | Consultation note - recommended C-CDA R1.1 sections | |||
| Indent51847-2 | Assessment+Plan | R | ||
| Indent51848-0 | Assessment | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent10164-2 | History of present illness | R | ||
| Indent29545-1 | Physical examination | R | ||
| Indent42349-1 | Reason for referral | R | ||
| Indent29299-5 | Reason for visit | R | ||
| Indent48765-2 | Allergies | O | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | O | ||
| Indent10154-3 | Chief complaint Narrative - Reported | O | ||
| Indent10157-6 | Family history | O | ||
| Indent10210-3 | General status | O | ||
| Indent11348-0 | Past medical history | O | ||
| Indent11369-6 | History of immunizations | O | ||
| Indent10160-0 | Medications | O | ||
| Indent11450-4 | Problems | O | ||
| Indent47519-4 | Procedures | O | ||
| Indent30954-2 | Results (Diagnostic findings) | O | ||
| Indent10187-3 | Review of systems | O | ||
| Indent29762-2 | Social history | O | ||
| Indent8716-3 | Vital signs | O |
Associated Observations
This panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections | |||
| Indent77599-9 | Additional documentation | R | ||
| Indent77598-1 | Externally defined clinical data elements Document | R | ||
| Indent47420-5 | Functional status assessment note | R | ||
| Indent77597-3 | Orders placed Document | R | ||
| Indent18776-5 | Plan of care note | R | ||
| Indent29762-2 | Social history Narrative | R | ||
| Indent77596-5 | Transportation summary Document | R | ||
| Indent42348-3 | Advance directives | O | ||
| Indent48765-2 | Allergies | R | ||
| Indent51847-2 | Evaluation + Plan note | R | ||
| Indent51848-0 | Evaluation note | R | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | R | ||
| Indent10154-3 | Chief complaint Narrative - Reported | R | ||
| Indent46240-8 | History of Hospitalizations+Outpatient visits Narrative | R | ||
| Indent10157-6 | History of family member diseases Narrative | R | ||
| Indent10210-3 | Physical findings of General status Narrative | R | ||
| Indent61146-7 | Goals Narrative | R | ||
| Indent75310-3 | Health concerns Document | R | ||
| Indent11383-7 | Patient problem outcome Narrative | R | ||
| Indent11348-0 | History of Past illness Narrative | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent11369-6 | History of Immunization Narrative | R | ||
| Indent69730-0 | Instructions | R | ||
| Indent62387-6 | Interventions Narrative | R | ||
| Indent46264-8 | History of medical device use | R | ||
| Indent10160-0 | History of Medication use Narrative | R | ||
| Indent10190-7 | Mental status Narrative | R | ||
| Indent61144-2 | Diet and nutrition Narrative | R | ||
| Indent61149-1 | Objective Narrative | R | ||
| Indent48768-6 | Payment sources Document | R | ||
| Indent29545-1 | Physical findings Narrative | R | ||
| Indent11450-4 | Problem list - Reported | R | ||
| Indent47519-4 | History of Procedures Document | R | ||
| Indent42349-1 | Reason for referral (narrative) | R | ||
| Indent29299-5 | Reason for visit Narrative | R | ||
| Indent30954-2 | Relevant diagnostic tests/laboratory data Narrative | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R | ||
| Indent61150-9 | Subjective Narrative | R | ||
| Indent8716-3 | Vital signs | R |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Change Reason
- Edit made because this term is conformant to the Document Ontology axis values and therefore are being placed in this class.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.; 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
- Both
- HL7 Attachment Structure
- Implementation guide exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups
| LG41826-5 | {Setting}| |
| LG38750-2 | Consultation note| |
Language Variants Get Info
- zh-CNChinese (China)
- 会诊记录:
发现: 时间点: {环境}: 文档型: {角色} - de-ATGerman (Austria)
- Befund:
Ergebnis: Zeitpunkt: {Setting}: Dokument: {Typ des Autors} - it-ITItalian (Italy)
- Nota di consulto:
Osservazione: Pt: {Setting}: Doc: {Role} - es-ARSpanish (Argentina)
- nota de consulta:
hallazgo: punto en el tiempo: {contexto}: Documento: {proveedor}
LOINC FHIR® API Example - CodeSystem Request Get Info
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=11488-4
LOINC Copyright
Copyright © 2021 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright