18761-7Transfer summary noteActive
Part Description
LP73546-1 Transfer summary note
Transfer summary notes are generated by the originating institution. The setting (when specified) is the facility the patient is being transferred out of (not where they are going).
Source: Regenstrief LOINC
Fully-Specified Name
- Component
- Transfer summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Transfer sum note
Associated Observations
This panel contains the recommended sections for transfer 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 |
---|---|---|---|---|
81614-0 | Transfer summary note - recommended C-CDA R2.1 sections | |||
Indent48765-2 | Allergies | R | ||
Indent51847-2 | Assessment+Plan | R | ||
Indent51848-0 | Assessment | R | ||
Indent18776-5 | Plan of care | R | ||
Indent10160-0 | History of Medication use Narrative | R | ||
Indent11450-4 | Problem list - Reported | R | ||
Indent42349-1 | Reason for referral (narrative) | R | ||
Indent30954-2 | Results | R | ||
Indent8716-3 | Vital signs | R | ||
Indent46241-6 | Hospital admission diagnosis Narrative - Reported | O | ||
Indent42346-7 | Medications on admission (narrative) | O | ||
Indent42348-3 | Advance directives | O | ||
Indent8648-8 | Hospital course Narrative | O | ||
Indent11535-2 | Hospital discharge Dx Narrative | O | ||
Indent46240-8 | History of Hospitalizations+Outpatient visits Narrative | O | ||
Indent10157-6 | History of family member diseases Narrative | O | ||
Indent47420-5 | Functional status assessment note | O | ||
Indent10210-3 | General status | O | ||
Indent11348-0 | History of Past illness Narrative | O | ||
Indent10164-2 | History of Present illness Narrative | O | ||
Indent11369-6 | History of Immunization Narrative | O | ||
Indent46264-8 | History of medical device use | O | ||
Indent10190-7 | Mental status Narrative | O | ||
Indent61144-2 | Diet and nutrition Narrative | O | ||
Indent48768-6 | Payment sources Document | O | ||
Indent29545-1 | Physical examination | O | ||
Indent47519-4 | Procedures | O | ||
Indent10187-3 | Review of systems | O | ||
Indent29762-2 | Social history | O |
Associated Observations
This panel contains the recommended sections for transfer 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 |
---|---|---|---|---|
81221-4 | Transfer summary note - recommended C-CDA R2.0 sections | |||
Indent48765-2 | Allergies | R | ||
Indent51847-2 | Assessment+Plan | R | ||
Indent51848-0 | Assessment | R | ||
Indent18776-5 | Plan of care | R | ||
Indent10160-0 | History of Medication use Narrative | R | ||
Indent11450-4 | Problem list - Reported | R | ||
Indent42349-1 | Reason for referral (narrative) | R | ||
Indent30954-2 | Results | R | ||
Indent8716-3 | Vital signs | R | ||
Indent46241-6 | Hospital admission diagnosis Narrative - Reported | O | ||
Indent42346-7 | Medications on admission (narrative) | O | ||
Indent42348-3 | Advance directives | O | ||
Indent8648-8 | Hospital course Narrative | O | ||
Indent11535-2 | Hospital discharge Dx Narrative | O | ||
Indent46240-8 | History of Hospitalizations+Outpatient visits Narrative | O | ||
Indent10157-6 | History of family member diseases Narrative | O | ||
Indent47420-5 | Functional status assessment note | O | ||
Indent10210-3 | General status | O | ||
Indent11348-0 | History of Past illness Narrative | O | ||
Indent10164-2 | History of Present illness Narrative | O | ||
Indent11369-6 | History of Immunization Narrative | O | ||
Indent46264-8 | History of medical device use | O | ||
Indent10190-7 | Mental status Narrative | O | ||
Indent61144-2 | Diet and nutrition Narrative | O | ||
Indent48768-6 | Payment sources Document | O | ||
Indent29545-1 | Physical examination | O | ||
Indent47519-4 | Procedures | O | ||
Indent10187-3 | Review of systems | O | ||
Indent29762-2 | Social history | O |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.58
- 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. Updated Component from "Transfer summarization note" to harmonize terms within the existing Document Ontology.; 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.
- 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}| |
LG38744-5 | Transfer summary note| |
Language Variants Get Info
- zh-CNChinese (China)
- 移交摘要记录:
发现: 时间点: {环境}: 文档型: {角色} - de-ATGerman (Austria)
- Transferbericht:
Ergebnis: Zeitpunkt: {Setting}: Dokument: {Typ des Autors} - it-ITItalian (Italy)
- Traferimento, nota di sintesi:
Osservazione: Pt: {Setting}: Doc: {Role} - es-ARSpanish (Argentina)
- TRANSFER SUMMARIZATION NOTE:
hallazgo: punto en el tiempo: {contexto}: Documento: {proveedor} - es-MXSpanish (Mexico)
- Transferir nota de resumen:
Tipo: Punto temporal: {Configuración}: Documento: {Role}
LOINC FHIR® API Example - CodeSystem Request Get Info
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=18761-7
LOINC Copyright
Copyright © 2022 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright