LOINC
Version 2.66

11490-0Physician Discharge summaryActive

Component
Discharge summary note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Physician

Additional Names

Short Name
MD Discharge sum

Part Description

LP72467-1   Discharge summary note
Discharge summary is a synopsis of a patient's admission to a hospital; it provides pertinent information for the continuation of care following discharge. The summary may include the reason for hospitalization, procedures performed, the care, treatment and services provided, the patient's condition and disposition at discharge, information provided to the patient and family, and provisions for follow-up care. Source: HL7

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.58
Change Reason
Changed Component from 'Discharge summarization note' per the Clinical LOINC Committee decision to harmonize existing terms in the LOINC Document Ontology.
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Associated Observations

This panel contains the recommended sections for discharge summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
81218-0 Discharge summary - recommended C-CDA R2.1 sections
Indent48765-2 Allergies R
Indent8648-8 Hospital course Narrative R
Indent78375-3 Discharge diagnosis Narrative R
Indent75311-1 Discharge medications Narrative R
Indent18776-5 Plan of care R
Indent42347-5 Admission diagnosis (narrative) O
Indent42346-7 Medications on admission (narrative) O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent42344-2 Discharge diet (narrative) O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent11348-0 History of Past illness Narrative O
Indent10164-2 History of Present illness Narrative O
Indent18841-7 Hospital consultations Document O
Indent8653-8 Hospital Discharge instructions O
Indent10184-0 Hospital discharge physical findings Narrative O
Indent11493-4 Hospital discharge studies summary Narrative O
Indent11369-6 History of Immunization Narrative O
Indent61144-2 Diet and nutrition Narrative O
Indent11450-4 Problem list - Reported O
Indent47519-4 History of Procedures Document O
Indent29299-5 Reason for visit Narrative O
Indent10187-3 Review of systems Narrative - Reported O
Indent29762-2 Social history Narrative O
Indent8716-3 Vital signs O

Associated Observations

This panel contains the recommended sections for discharge summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.0.

LOINC Name R/O/C Cardinality Example UCUM Units
81219-8 Discharge summary - recommended C-CDA R2.0 sections
Indent48765-2 Allergies R
Indent8648-8 Hospital course Narrative R
Indent11535-2 Hospital discharge Dx Narrative R
Indent10183-2 Hospital discharge medications Narrative R
Indent18776-5 Plan of care R
Indent46241-6 Hospital admission diagnosis Narrative - Reported O
Indent42346-7 Medications on admission (narrative) R
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent42344-2 Discharge diet (narrative) O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent11348-0 History of Past illness Narrative O
Indent10164-2 History of Present illness Narrative O
Indent18841-7 Hospital consultations Document O
Indent8653-8 Hospital Discharge instructions O
Indent10184-0 Hospital discharge physical findings Narrative O
Indent11493-4 Hospital discharge studies summary Narrative O
Indent11369-6 History of Immunization Narrative O
Indent61144-2 Diet and nutrition Narrative O
Indent11450-4 Problem list - Reported O
Indent47519-4 History of Procedures Document O
Indent29299-5 Reason for visit Narrative O
Indent10187-3 Review of systems Narrative - Reported O
Indent29762-2 Social history Narrative O
Indent8716-3 Vital signs O

Associated Observations

This panel contains the recommended sections for discharge summary 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
72229-8 Discharge summary - recommended C-CDA R1.1 sections
Indent48765-2 Allergies R
Indent8648-8 Hospital course Narrative R
Indent11535-2 Hospital discharge Dx Narrative R
Indent10183-2 Hospital discharge medications Narrative R
Indent18776-5 Plan of care R
Indent10154-3 Chief complaint Narrative - Reported O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent42344-2 Discharge diet (narrative) O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent10164-2 History of Present illness Narrative O
Indent46241-6 Hospital admission diagnosis Narrative - Reported O
Indent18841-7 Hospital consultations Document O
Indent8653-8 Hospital Discharge instructions O
Indent10184-0 Hospital discharge physical findings Narrative O
Indent11348-0 History of Past illness Narrative O
Indent47519-4 History of Procedures Document O
Indent11369-6 History of Immunization Narrative O
Indent11450-4 Problem list - Reported O
Indent11493-4 Hospital discharge studies summary Narrative O
Indent29299-5 Reason for visit Narrative O
Indent10187-3 Review of systems Narrative - Reported O
Indent29762-2 Social history Narrative O
Indent8716-3 Vital signs O

Associated Observations

This panel contains the recommended sections for an enhanced discharge summary note based on the HL7 Clinical Documents for Payers - Set 1, Release 1.0 (US Realm).

LOINC Name R/O/C Cardinality Example UCUM Units
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 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
Indent46241-6 Hospital admission diagnosis Narrative - Reported R
Indent42346-7 Medications on admission (narrative) R
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
Indent11535-2 Hospital discharge Dx Narrative R
Indent10183-2 Hospital discharge medications Narrative R
Indent10157-6 History of family member diseases Narrative R
Indent47420-5 Functional status assessment note 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
Indent18841-7 Hospital consultations Document R
Indent8648-8 Hospital course Narrative R
Indent8653-8 Hospital Discharge instructions R
Indent10184-0 Hospital discharge physical findings Narrative R
Indent11493-4 Hospital discharge studies summary Narrative R
Indent11369-6 History of Immunization Narrative R
Indent69730-0 Instructions R
Indent11329-0 History general Narrative - Reported 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
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
Indent29299-5 Reason for visit Narrative R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent10187-3 Review of systems Narrative - Reported R
Indent8716-3 Vital signs R

Member of these Panels

LOINC Long Common Name
26443-2 Clinical reports.non lab claims attachment

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38746-0 Discharge summary note|ANYRole|ANYSetting
LG38946-6 Physician|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
出院摘要记录:发现:时间点:{环境}:文档型:医师
nl-NLDutch (Netherlands)
samenvattende ontslagbrief:bevinding:moment:{instelling}:document:arts
de-ATGerman (Austria)
Entlassungsbrief Ärztlich:Ergebnis:Zeitpunkt:{Setting}:Dokument:Arzt
it-ITItalian (Italy)
Lettera di dimissione ospedaliera:Osservazione:Pt:{Setting}:Doc:Medico
es-ARSpanish (Argentina)
nota de resumen en el momento del alta:hallazgo:punto en el tiempo:{contexto}:Documento:médico

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=11490-0