LOINC
Version 2.68

34133-9Summary of episode noteActive

Term Description

This LOINC term is currently used as the Clinical Document code for both the Care Record Summary (CRS) and Continuity of Care Document (CCD).
Source: Regenstrief LOINC

Part Description

LP73427-4   Summary of episode note
Summarization of Episode Note contains an aggregate of pertinent data about a patient from a health care episode. 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

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.09
Last Updated
Version 2.63
Change Reason
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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Associated Observations

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

Associated Observations

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

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

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

Language Variants Get Info

zh-CNChinese (CHINA)
病程摘要记录:发现:时间点:{环境}:文档型:{角色}
it-ITItalian (ITALY)
Nota di sintesi di episodio:Osservazione:Pt:{Setting}:Doc:{Role}
es-ARSpanish (ARGENTINA)
nota con síntesis sobre el episodio:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}

LOINC FHIR® API Example - CodeSystem Request Get Info

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