LOINC
Version 2.71

34121-4Interventional procedure noteActive

Fully-Specified Name

Component
Interventional procedure note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Interv proced note

Associated Observations

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

LOINC Name R/O/C Cardinality Example UCUM Units
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent55109-3 Complications Document R
Indent29554-3 Procedure description R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent48765-2 Allergies O
Indent59774-0 Procedure anesthesia Narrative O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent10157-6 Family history O
Indent11348-0 History of Past illness Narrative O
Indent10164-2 History of Present illness Narrative O
Indent11348-0 Past medical history O
Indent29549-3 Medication administered Narrative O
Indent10160-0 Medications O
Indent29545-1 Physical examination O
Indent59772-4 Planned procedure Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59770-8 Procedure estimated blood loss Narrative O
Indent59776-5 Procedure findings Narrative O
Indent59771-6 Procedure implants Narrative O
Indent59773-2 Procedure specimens taken Narrative O
Indent47519-4 History of Procedures Document O
Indent29299-5 Reason for visit O
Indent10187-3 Review of systems Narrative - Reported O
Indent29762-2 Social history Narrative O

Associated Observations

This panel contains the recommended sections for procedure notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.

LOINC Name R/O/C Cardinality Example UCUM Units
59843-3 Procedure note - recommended C-CDA R1.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent55109-3 Complications Document R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent29554-3 Procedure description R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent59770-8 Procedure estimated blood loss Narrative O
Indent59771-6 Procedure implants Narrative O
Indent59772-4 Planned procedure Narrative O
Indent59773-2 Procedure specimens taken Narrative O
Indent59774-0 Procedure anesthesia Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59776-5 Procedure findings Narrative O
Indent29545-1 Physical examination R
Indent29299-5 Reason for visit C
Indent48765-2 Allergies O
Indent10154-3 Chief complaint Narrative - Reported O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10157-6 Family history O
Indent10210-3 General status O
Indent11348-0 Past medical history O
Indent10160-0 Medications O
Indent29549-3 Medication administered Narrative O
Indent47519-4 History of Procedures Document O
Indent29762-2 Social history Narrative O
Indent10187-3 Review of systems Narrative - Reported O

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.09
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
Implementation guide exists

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38763-5 Interventional procedure note|ANYRole|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
干预性操作记录:发现:时间点:{环境}:文档型:{角色}
it-ITItalian (Italy)
Procedura interventistica, nota:Osservazione:Pt:{Setting}:Doc:{Role}
es-ARSpanish (Argentina)
INTERVENTIONAL PROCEDURE NOTE:hallazgo:punto en el tiempo:{contexto}:Documento:

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=34121-4