Version 2.74

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

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38742-9 Initial evaluation note|ANYRole|ANYSetting

Language Variants

Tag Language Translation
zh-CN Chinese (China) 初步评价记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 初步（初始、早期、最初、原始）（评估、测评、评测、评判）记录 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书 评价（评估、测评、评测、评判、评定、判定、评量、核定）记录;评估记录 评估 评定 鉴定
es-AR Spanish (Argentina) nota de evaluación inicial:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}
es-MX Spanish (Mexico) Nota de evaluación inicial:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Nota di valutazione iniziale:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di valutazione Osservazione Punto nel tempo (episodio) Ruolo non specificato

LOINC Terminology Service (API) using HL7® FHIR®

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=28636-9