28563-5
Care provider notes Set
Active
28654-2 Attending Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Attending
Additional Names
- Short Name
- Attend Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.65
- Change Reason
- Changed Method from 'Attending physician' to 'Physician attending'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values.; Updated "Physician attending" in Method to "Attending" based on Clinical LOINC Committee review and approval (10/2018).
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39003-5 | Attending| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
18733-6 Attending Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Attending
Additional Names
- Short Name
- Attend Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.73
- Change Reason
- Changed Method from 'Attending physician' to 'Physician attending'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values. Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Updated "Physician attending" in Method to "Attending" based on Clinical LOINC Committee review and approval (10/2018).
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39003-5 | Attending| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28581-7 Chiropractic medicine Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Chiropractic medicine
Additional Names
- Short Name
- Chiropractic med Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39074-6 | Chiropractic medicine| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: chiropraxie evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28580-9 Chiropractic medicine Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Chiropractic medicine
Additional Names
- Short Name
- Chiropractic med Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39074-6 | Chiropractic medicine| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evolución: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: Synonyms: chiropraxie |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28572-6 Dentistry Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28583-3 Dentist Operation note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Operative note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de intervención quirúrgica: |
| es-MX | Spanish (Mexico) | Nota de operación quirúrgica: |
| fr-BE | French (Belgium) | Note opération chirurgicale.: |
| it-IT | Italian (Italy) | Nota di operazione chirurgica: Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | operatieverslag: |
| zh-CN | Chinese (China) | 外科手术记录: Synonyms: 临床文档型; |
28577-5 Dentistry procedure note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Procedure note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38811-2 | Procedure note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de procedimiento: |
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| fr-BE | French (Belgium) | Note de procédure: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: verslag procedure |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
28617-9 Dentistry Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. 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.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| pt-BR | Portuguese (Brazil) | Anotação de avaliação subsequente: Synonyms: ; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28618-7 Dentistry Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Dentistry
Additional Names
- Short Name
- Dentistry Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.52
- Change Reason
- Component was changed from 'Visit note' to 'Note'. Edit based on Clinical LOINC Committee approval at 8/16/2011 meeting to harmonize existing terms with Document Ontology values.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38956-5 | Dentistry| |
| LG38748-6 | Note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: |
| pt-BR | Portuguese (Brazil) | Anotação de visita: Synonyms: Finding; |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
34745-0 Nurse Discharge summary
Part Descriptions
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
Fully-Specified Name
- Component
- Discharge summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse D/C sum
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.11
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38746-0 | Discharge summary note| |
| LG38952-4 | Nurse| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Entlassungsbrief Ärztlich: Synonyms: Bericht Entlassungsbrief aus stationärer Behandlung (Arzt); |
| es-AR | Spanish (Argentina) | nota de resumen en el momento del alta: |
| es-MX | Spanish (Mexico) | Nota de resumen de alta: |
| fr-BE | French (Belgium) | Note résumée de sortie: |
| it-IT | Italian (Italy) | Lettera di dimissione ospedaliera: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | samenvattende ontslagbrief: |
| zh-CN | Chinese (China) | 出院摘要记录: Synonyms: 临床文档型; |
29753-1 Nurse Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.03
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38952-4 | Nurse| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28623-7 Nurse Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also 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.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38952-4 | Nurse| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| pt-BR | Portuguese (Brazil) | Anotação de avaliação subsequente: Synonyms: ; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28651-8 Nurse Transfer note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Transfer summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse Transfer sum note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Change Reason
- Updated Component from "Transfer summarization note" to harmonize terms within the existing Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38952-4 | Nurse| |
| LG38744-5 | Transfer summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Transferbericht: Synonyms: Bericht Transferbericht |
| es-AR | Spanish (Argentina) | TRANSFER SUMMARIZATION NOTE: |
| es-MX | Spanish (Mexico) | Transferir nota de resumen: |
| fr-BE | French (Belgium) | Note résumée de transfert: |
| it-IT | Italian (Italy) | Traferimento, nota di sintesi: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | samenvatting van overdracht: |
| zh-CN | Chinese (China) | 移交摘要记录: Synonyms: 临床文档型; |
28621-1 Nurse practitioner Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse practitioner
Additional Names
- Short Name
- Nurse pract Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG39002-7 | Nurse practitioner| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Anotação de avaliação inicial: Synonyms: ; |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28575-9 Nurse practitioner Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Nurse practitioner
Additional Names
- Short Name
- Nurse pract Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39002-7 | Nurse practitioner| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evolución: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18734-4 Occupational therapy Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Occupational therapy
Additional Names
- Short Name
- OT Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38947-4 | Occupational therapy| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11507-1 Occupational therapy Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Occupational therapy
Additional Names
- Short Name
- OT Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. lso changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38947-4 | Occupational therapy| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28578-3 Occupational therapy Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Occupational therapy
Additional Names
- Short Name
- OT Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.52
- Change Reason
- Component was changed from 'Visit note' to 'Note', systerm was changed from ^Patient to {setting} and class was changed from ATTACH.CLINRPT to DOC.CLINRPT based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that 'Occupational therapy visit note', for example, is essentially the same as a 'Occupational therapy note'. Other parts of term were changed to correspond with current document ontology.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38947-4 | Occupational therapy| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Befund: Synonyms: Bericht |
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
18735-1 Physical therapy Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physical therapy
Additional Names
- Short Name
- PT Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38948-2 | Physical therapy| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11508-9 Physical therapy Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physical therapy
Additional Names
- Short Name
- PT Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. lso changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38948-2 | Physical therapy| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28579-1 Physical therapy Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physical therapy
Additional Names
- Short Name
- PT Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.52
- Change Reason
- Component was changed from 'Visit note' to 'Note' and class was changed from ATTACH.CLINRPT to DOC.CLINRPT. Edits based on Clinical LOINC Committee approval at 8/16/2011 meeting to harmonize existing terms with Document Ontology values.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38948-2 | Physical therapy| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Befund: Synonyms: Bericht |
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
28568-4 Physician Emergency department Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- Emergency department
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD ED Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Component was changed from 'Visit note' to 'Note' based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that Occupational therapy visit note, for example, is essentially the same as a Occupational therapy note.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 7894
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41825-7 | Emergency department| |
| LG38748-6 | Note| |
| LG38946-6 | Physician| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: Synonyms: SEH |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
11490-0 Physician Discharge summary
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Discharge summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD D/C sum
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- 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
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38746-0 | Discharge summary note| |
| LG38946-6 | Physician| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Entlassungsbrief Ärztlich: Synonyms: Bericht Entlassungsbrief aus stationärer Behandlung (Arzt); |
| es-AR | Spanish (Argentina) | nota de resumen en el momento del alta: |
| es-MX | Spanish (Mexico) | Nota de resumen de alta: |
| it-IT | Italian (Italy) | Lettera di dimissione ospedaliera: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | samenvattende ontslagbrief: |
| zh-CN | Chinese (China) | 出院摘要记录: Synonyms: 临床文档型; |
18736-9 Physician Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38946-6 | Physician| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28626-0 Physician History and physical note
Part Descriptions
LP72701-3 History and physical note
History and physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- History and physical note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD H&P note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- 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.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38753-6 | History and physical note| |
| LG38946-6 | Physician| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | HISTORY & PHYSICAL NOTE: |
| es-MX | Spanish (Mexico) | Historia y nota física: |
| it-IT | Italian (Italy) | Anamnesi e visita medica: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag voorgeschiedenis en lichamelijk onderzoek: |
| pt-BR | Portuguese (Brazil) | Histórico e anotações físicas: Synonyms: ; |
| zh-CN | Chinese (China) | 病史与体格检查记录: Synonyms: 临床文档型; |
28573-4 Physician, Operation note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD Operative note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38946-6 | Physician| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Operationsbericht: Synonyms: Bericht OP-Bericht |
| es-AR | Spanish (Argentina) | nota de intervención quirúrgica: |
| es-MX | Spanish (Mexico) | Nota de operación quirúrgica: |
| it-IT | Italian (Italy) | Nota di operazione chirurgica: Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | operatieverslag: |
| zh-CN | Chinese (China) | 外科手术记录: Synonyms: 临床文档型; |
11505-5 Physician procedure note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD Procedure note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38946-6 | Physician| |
| LG38811-2 | Procedure note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de procedimiento: |
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: verslag procedure |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
28616-1 Physician Transfer note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Transfer summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physician
Additional Names
- Short Name
- MD Transfer sum note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Change Reason
- Updated Component from "Transfer summarization note" to harmonize terms within the existing Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38946-6 | Physician| |
| LG38744-5 | Transfer summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Transferbericht: Synonyms: Bericht Transferbericht |
| es-AR | Spanish (Argentina) | TRANSFER SUMMARIZATION NOTE: |
| es-MX | Spanish (Mexico) | Transferir nota de resumen: |
| it-IT | Italian (Italy) | Traferimento, nota di sintesi: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | samenvatting van overdracht: |
| pt-BR | Portuguese (Brazil) | Anotação resumo de transferência: Synonyms: ; |
| zh-CN | Chinese (China) | 移交摘要记录: Synonyms: 临床文档型; |
28569-2 Consultant Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Consultant
Additional Names
- Short Name
- Consultant Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Changed Method from 'Consulting physician' to 'Physician consulting'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values. Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also canged class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Changed Method from "Physician consulting" to 'Consultant' based on Clinical LOINC Committee approval at 10/2018 meeting to remove "Physician" from Role values that could be used for non-physician specialities.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39015-9 | Consultant| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18763-3 Consultant Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Consultant
Additional Names
- Short Name
- Consultant Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.65
- Change Reason
- Changed Method from 'Consulting physician' to 'Physician consulting'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values.; Changed Method from "Physician consulting" to 'Consultant' based on Clinical LOINC Committee approval at 10/2018 meeting to remove "Physician" from Role values that could be used across non-physician type specialities.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG39015-9 | Consultant| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
18737-7 Podiatry Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Podiatry
Additional Names
- Short Name
- Podiatry Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38949-0 | Podiatry| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28624-5 Podiatry Operation note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Podiatry
Additional Names
- Short Name
- Podiatry Operative note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38949-0 | Podiatry| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de intervención quirúrgica: |
| es-MX | Spanish (Mexico) | Nota de operación quirúrgica: |
| fr-BE | French (Belgium) | Note opération chirurgicale.: |
| it-IT | Italian (Italy) | Nota di operazione chirurgica: Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | operatieverslag: |
| pt-BR | Portuguese (Brazil) | Anotação de cirurgia: Synonyms: ; |
| zh-CN | Chinese (China) | 外科手术记录: Synonyms: 临床文档型; |
28625-2 Podiatry procedure note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Podiatry
Additional Names
- Short Name
- Podiatry Procedure note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38949-0 | Podiatry| |
| LG38811-2 | Procedure note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de procedimiento: |
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| fr-BE | French (Belgium) | Note de procédure: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: verslag procedure |
| pt-BR | Portuguese (Brazil) | Anotação de procedimento: Synonyms: Finding; |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
11509-7 Podiatry Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Podiatry
Additional Names
- Short Name
- Podiatry Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38949-0 | Podiatry| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
11488-4 Consult note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Consultation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Consult note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Previous Releases: 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.;
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 9056
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38750-2 | Consultation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Befund: Synonyms: Bericht |
| es-AR | Spanish (Argentina) | nota de consulta: |
| es-MX | Spanish (Mexico) | Nota de consulta: |
| it-IT | Italian (Italy) | Nota di consulto: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | consultverslag: Synonyms: consultatie-aantekening |
| zh-CN | Chinese (China) | 会诊记录: Synonyms: 临床文档型; |
15507-7 Emergency department Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- Emergency department
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- ED Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0k
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since 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.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41825-7 | Emergency department| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: Synonyms: SEH |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
11492-6 Provider-unspecifed, History and physical note
Part Descriptions
LP72701-3 History and physical note
History and physical (H&P) note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- History and physical note
- Property
- Find
- Time
- Pt
- System
- Hospital
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Hosp H&P note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- 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.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 17187
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG38753-6 | History and physical note| |
| LG41829-9 | Hospital| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | HISTORY & PHYSICAL NOTE: |
| es-MX | Spanish (Mexico) | Historia y nota física: |
| it-IT | Italian (Italy) | Anamnesi e visita medica: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | verslag voorgeschiedenis en lichamelijk onderzoek: |
| zh-CN | Chinese (China) | 病史与体格检查记录: Synonyms: 临床文档型; |
18842-5 Discharge summary
Part Descriptions
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
Fully-Specified Name
- Component
- Discharge summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- D/C sum
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.73
- 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. Changed Component from 'Discharge summarization note' per the Clinical LOINC Committee decision to harmonize existing terms in the LOINC 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
- Common Test Rank Get Info
- 5023
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38746-0 | Discharge summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Entlassungsbrief Ärztlich: Synonyms: Bericht Entlassungsbrief aus stationärer Behandlung (Arzt); |
| es-AR | Spanish (Argentina) | nota de resumen en el momento del alta: |
| es-MX | Spanish (Mexico) | Nota de resumen de alta: |
| it-IT | Italian (Italy) | Lettera di dimissione ospedaliera: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | samenvattende ontslagbrief: |
| pt-BR | Portuguese (Brazil) | Anotação resumo de alta médica: Synonyms: ; |
| zh-CN | Chinese (China) | 出院摘要记录: Synonyms: 临床文档型; |
28636-9 Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- 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.; 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
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11504-8 Surgical operation note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Operative note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.63
- Change Reason
- Previous Releases: 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.;
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Operationsbericht: Synonyms: Bericht OP-Bericht |
| es-AR | Spanish (Argentina) | nota de intervención quirúrgica: |
| es-MX | Spanish (Mexico) | Nota de operación quirúrgica: |
| it-IT | Italian (Italy) | Nota di operazione chirurgica: Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | operatieverslag: |
| zh-CN | Chinese (China) | 外科手术记录: Synonyms: 临床文档型; |
28570-0 Procedure note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Procedure note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.58
- Change Reason
- 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
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
| 93340-8 | PhenX - complete blood count protocol 220501 |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38811-2 | Procedure note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de procedimiento: |
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: verslag procedure |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
11506-3 Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- 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 approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note.; 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
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18761-7 Transfer summary note
Part Descriptions
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
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Transfer summary note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- Transfer sum note
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
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38744-5 | Transfer summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Transferbericht: Synonyms: Bericht Transferbericht |
| es-AR | Spanish (Argentina) | TRANSFER SUMMARIZATION NOTE: |
| es-MX | Spanish (Mexico) | Transferir nota de resumen: |
| it-IT | Italian (Italy) | Traferimento, nota di sintesi: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | samenvatting van overdracht: |
| zh-CN | Chinese (China) | 移交摘要记录: Synonyms: 临床文档型; |
28635-1 Psychiatry Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychiatry
Additional Names
- Short Name
- Psychiatric Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38973-0 | Psychiatry| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28627-8 Psychiatry Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychiatry
Additional Names
- Short Name
- Psychiatric Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG38973-0 | Psychiatry| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| pt-BR | Portuguese (Brazil) | Anotação de avaliação subsequente: Synonyms: ; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
11527-9 Psychiatry study
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Psychiatry study
- Property
- Find
- Time
- Pt
- System
- ^Patient
- Scale
- Doc
- Method
- Psychiatry
Additional Names
- Short Name
- Psychiatry study
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.72
- Change Reason
- Release 2.72: COMPONENT: Updated to reflect naming convention;
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe del estudio: |
| es-MX | Spanish (Mexico) | Informe de estudio: |
| it-IT | Italian (Italy) | Psichiatria, studio: Synonyms: Clinico Osservazione paziente Punto nel tempo (episodio) Studio di psichiatria |
| nl-NL | Dutch (Netherlands) | psychiatrisch onderzoek: |
| pt-BR | Portuguese (Brazil) | Relatório: Synonyms: Finding; |
| zh-CN | Chinese (China) | 精神病学检查: Synonyms: 临床文档型; |
28628-6 Psychiatry Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychiatry
Additional Names
- Short Name
- Psychiatric Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.52
- Change Reason
- Component was changed from 'Visit note' to 'Note', systerm was changed from ^Patient to {setting} and class was changed from ATTACH.CLINRPT to DOC.CLINRPT based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that 'Occupational therapy visit note', for example, is essentially the same as a 'Occupational therapy note'. Other parts of term were changed to correspond with current document ontology.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38973-0 | Psychiatry| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Befund: Synonyms: Bericht Psychiatrie |
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag: |
| pt-BR | Portuguese (Brazil) | Anotação de visita: Synonyms: Finding; |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
18738-5 Psychology Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychology
Additional Names
- Short Name
- Psych Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38950-8 | Psychology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verslag eerste onderzoek: Synonyms: evaluatieverslag |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11510-5 Psychology Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Psychology
Additional Names
- Short Name
- Psych Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG38950-8 | Psychology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| nl-NL | Dutch (Netherlands) | voortgangsrapport: |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18739-3 Social worker Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Social worker
Additional Names
- Short Name
- SW Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.65
- Change Reason
- Changed Method from "Social work" to "Social worker" based on the Clinical LOINC Committee decision (10/2018) to represent Social work/er as a Role value in the LOINC Document Ontology.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38995-3 | Social worker| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
28653-4 Social worker Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Social worker
Additional Names
- Short Name
- SW Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Component was changed from 'Visit note' to 'Note' and method was changed from 'Social service' to 'Social work'. Changed class from ATTACH.CLINRPT to DOC.CLINRPT. Edits based on Clinical LOINC Committee approval at 8/16/2011 meeting to harmonize existing terms with Document Ontology values.; Changed Method from "Social work" to "Social worker" based on the Clinical LOINC Committee decision (10/2018) to represent Social work/er as a Role value in the LOINC Document Ontology.
- Order vs. Observation
- Both
- Common Test Rank Get Info
- 6253
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38995-3 | Social worker| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |
28656-7 Social worker Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Social worker
Additional Names
- Short Name
- SW Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.; Changed Method from "Social work" to "Social worker" based on the Clinical LOINC Committee decision (10/2018) to represent Social work/er as a Role value in the LOINC Document Ontology.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG38995-3 | Social worker| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
18740-1 Speech-language pathology Initial evaluation note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Initial evaluation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Speech-language pathology
Additional Names
- Short Name
- Speech-lang path Initial eval note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0l
- Last Updated
- Version 2.50
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38742-9 | Initial evaluation note| |
| LG38951-6 | Speech-language pathology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | nota de evaluación inicial: |
| es-MX | Spanish (Mexico) | Nota de evaluación inicial: |
| fr-BE | French (Belgium) | Note initiale d'évaluation: Synonyms: Anatomo-pathologie |
| it-IT | Italian (Italy) | Nota di valutazione iniziale: Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 初步评价记录: Synonyms: 临床文档型; |
11512-1 Speech-language pathology Progress note
Part Descriptions
LP74253-3 Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.
Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."
Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."
A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report.
Source: HL7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Speech-language pathology
Additional Names
- Short Name
- Speech-lang path Prog note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 1.0j-a
- Last Updated
- Version 2.73
- Change Reason
- Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. Also changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- IG exists
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG38951-6 | Speech-language pathology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | SUBSEQUENT EVALUATION NOTE: |
| es-MX | Spanish (Mexico) | Nota de progreso: |
| fr-BE | French (Belgium) | Note de progrès: Synonyms: Anatomo-pathologie |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
28571-8 Speech-language pathology Note
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Speech-language pathology
Additional Names
- Short Name
- Speech-lang path Note
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.00
- Last Updated
- Version 2.50
- Change Reason
- Component was changed from 'Visit note' to 'Note' based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that Occupational therapy visit note, for example, is essentially the same as a Occupational therapy note.
- Order vs. Observation
- Both
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 26443-2 | Clinical reports.non lab claims attachment |
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38748-6 | Note| |
| LG38951-6 | Speech-language pathology| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | informe de la consulta: |
| es-MX | Spanish (Mexico) | Nota: |
| fr-BE | French (Belgium) | Note: Synonyms: Anatomo-pathologie |
| it-IT | Italian (Italy) | Nota: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 记录: Synonyms: 临床文档型; |