Version 2.78

Term Description

This LOINC term is commonly used as the Clinical Document code for both the Care Record Summary (CRS) and Continuity of Care Document (CCD), with an "episode" of care defined as the provision of care over a specified period of time that can cover one or more health care encounters. This definition was approved by the LOINC Document Ontology subcommittee in February 2021.
Source: Regenstrief LOINC

Part Description

LP73427-4   Summary of episode note
Summarization of Episode Note contains pertinent data about the provision of care for a patient over a specified period of time. Examples include a Care Record Summary (CRS) and Continuity of Care Document (CCD). CRS includes the summary of the episode, discharge and transfer. CCD includes the most relevant administrative, demographic, and clinical information about a patient's healthcare, covering one or more healthcare encounters. Such documents are commonly used in Transfer of Care scenarios. Source: HL7

Fully-Specified Name

Component
Summary of episode note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Summary of episode note

Associated Observations

81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections

This panel contains the recommended sections for the continuity of care document [LOINC: 34133-9] 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
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
Indent48765-2 Allergies R
Indent10160-0 History of Medication use Narrative R
Indent11450-4 Problem list - Reported R
Indent47519-4 History of Procedures Document R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent29762-2 Social history R
Indent8716-3 Vital signs R
Indent42348-3 Advance directives O
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent11369-6 History of Immunization Narrative O
Indent10190-7 Mental status Narrative O
Indent46264-8 History of medical device use O
Indent61144-2 Diet and nutrition Narrative O
Indent48768-6 Payment sources Document O
Indent18776-5 Plan of care note O

72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections

This panel contains the recommended sections for the continuity of care document [LOINC: 34133-9] 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
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
Indent48765-2 Allergies R
Indent10160-0 History of Medication use Narrative R
Indent11450-4 Problem list - Reported R
Indent47519-4 History of Procedures Document R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent42348-3 Advance directives O
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent11369-6 History of Immunization Narrative O
Indent46264-8 History of medical device use O
Indent48768-6 Payment sources Document O
Indent18776-5 Plan of care note O
Indent29762-2 Social history O
Indent8716-3 Vital signs O

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.09
Last Updated
Version 2.70
Change Reason
Release 2.70: DefinitionDescription: Added definition of "episode of care"; Previous Releases: Changed Component from 'Summarization of episode' per Clinical LOINC Committee decision to harmonize existing Document Ontology axes values.; Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Panels

LOINC Long Common Name
69459-6 Care record summary panel
48769-4 Continuity of Care panel
74293-2 Oncology plan of care and summary - recommended CDA set

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38814-6 Summary of episode note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Krankengeschichte
de-DE German (Germany) Zusammenfassung der Behandlungsepisode - Notiz:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-AR Spanish (Argentina) nota con síntesis sobre el episodio:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}
es-MX Spanish (Mexico) Resumen de la nota del episodio:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Nota di sintesi di episodio:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di riepilogo di episodio Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) samenvatting van episode:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 病程摘要记录: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;插曲;片断;场面;情节;发作 事件发生的地方;场景;环境;背景 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 病程（医疗服务历程、照护服务历程、照护历程、医疗护理服务历程、医疗护理历程、医疗历程、历程、情节、事件、片段、照护服务片段、照护片段、照护情节、照护事件、发生期、患病期、发作期、事件发生期、情节发生期、事件持续时间、情节持续时间、次、回）摘要（小结、概要、总结、梗概、概括、总汇）记录 笔记;按语;注释;说明;票据;单据;证明书

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=34133-9