LOINC
Version 2.66

11504-8Surgical operation noteActive

Component
Surgical operation note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Operative note

Part Description

LP73465-4   Surgical operation note
Surgical operation note (Operative note) is note or report created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnoses, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report provides details to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care. Source: HL7

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63
Change Reason
Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits made because this term is conformant to the Document Ontology axis values and therefore 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

Associated Observations

This panel contains the recommended sections for surgical operation notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
Indent59774-0 Procedure anesthesia Narrative R
Indent55109-3 Complications Document R
Indent10218-6 Surgical operation note postoperative diagnosis Narrative R
Indent10219-4 Surgical operation note preoperative diagnosis Narrative R
Indent59770-8 Procedure estimated blood loss Narrative R
Indent59776-5 Procedure findings Narrative R
Indent59773-2 Procedure specimens taken Narrative R
Indent29554-3 Procedure Narrative R
Indent59771-6 Procedure implants Narrative O
Indent10216-0 Surgical operation note fluids Narrative O
Indent10223-6 Surgical operation note surgical procedure Narrative O
Indent18776-5 Plan of care note O
Indent59772-4 Planned procedure Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59768-2 Procedure indications [Interpretation] Narrative O
Indent11537-8 Surgical drains Narrative O

Associated Observations

This panel contains the recommended sections for an enhanced surgical operation 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
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
Indent77599-9 Additional documentation R
Indent77598-1 Externally defined clinical data elements Document R
Indent77597-3 Orders placed Document R
Indent18776-5 Plan of care note R
Indent59774-0 Procedure anesthesia Narrative R
Indent55109-3 Complications Document R
Indent46264-8 History of medical device use R
Indent10216-0 Surgical operation note fluids Narrative R
Indent10223-6 Surgical operation note surgical procedure Narrative R
Indent48768-6 Payment sources Document R
Indent59772-4 Planned procedure Narrative R
Indent10218-6 Surgical operation note postoperative diagnosis Narrative R
Indent10219-4 Surgical operation note preoperative diagnosis Narrative R
Indent29554-3 Procedure Narrative R
Indent59775-7 Procedure disposition Narrative R
Indent59770-8 Procedure estimated blood loss Narrative R
Indent59776-5 Procedure findings Narrative R
Indent59771-6 Procedure implants Narrative R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent59773-2 Procedure specimens taken Narrative R
Indent11537-8 Surgical drains Narrative 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
LG38755-1 Surgical operation note|ANYRole|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
外科手术记录:发现:时间点:{环境}:文档型:{角色}
de-ATGerman (Austria)
Operationsbericht:Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}
it-ITItalian (Italy)
Nota di operazione chirurgica:Osservazione:Pt:{Setting}:Doc:{Role}
es-ARSpanish (Argentina)
nota de intervención quirúrgica: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=11504-8