Version 2.76

Part Description

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

Fully-Specified Name

Component
Surgical operation note
Property
Find
Time
Pt
System
Outpatient
Scale
Doc
Method
{Role}

Additional Names

Short Name
OP Operative note

Associated Observations

72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

This panel contains the recommended sections for surgical operation notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
Indent59774-0 Procedure anesthesia Narrative R
Indent55109-3 Complications Document R
Indent10218-6 Surgical operation note postoperative diagnosis Narrative R
Indent10219-4 Surgical operation note preoperative diagnosis Narrative R
Indent59770-8 Procedure estimated blood loss Narrative R
Indent59776-5 Procedure findings Narrative R
Indent59773-2 Procedure specimens taken Narrative R
Indent29554-3 Procedure Narrative R
Indent59771-6 Procedure implants Narrative O
Indent10216-0 Surgical operation note fluids Narrative O
Indent10223-6 Surgical operation note surgical procedure Narrative O
Indent18776-5 Plan of care note O
Indent59772-4 Planned procedure Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59768-2 Procedure indications [Interpretation] Narrative O
Indent11537-8 Surgical drains Narrative O

81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections

This panel contains the recommended sections for an enhanced surgical operation note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).

LOINC Name R/O/C Cardinality Example UCUM Units
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
Indent77599-9 Additional documentation R
Indent77598-1 Externally defined clinical data elements Document R
Indent77597-3 Orders placed Document R
Indent18776-5 Plan of care note R
Indent59774-0 Procedure anesthesia Narrative R
Indent55109-3 Complications Document R
Indent46264-8 History of medical device use R
Indent10216-0 Surgical operation note fluids Narrative R
Indent10223-6 Surgical operation note surgical procedure Narrative R
Indent48768-6 Payment sources Document R
Indent59772-4 Planned procedure Narrative R
Indent10218-6 Surgical operation note postoperative diagnosis Narrative R
Indent10219-4 Surgical operation note preoperative diagnosis Narrative R
Indent29554-3 Procedure Narrative R
Indent59775-7 Procedure disposition Narrative R
Indent59770-8 Procedure estimated blood loss Narrative R
Indent59776-5 Procedure findings Narrative R
Indent59771-6 Procedure implants Narrative R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent59773-2 Procedure specimens taken Narrative R
Indent11537-8 Surgical drains Narrative R

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 Get Info

LOINC Group Group Name
LG41828-1 Outpatient|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38755-1 Surgical operation note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Operationsbericht:Ergebnis:Zeitpunkt:ambulant:Dokument:{Typ des Autors}
Synonyms: Bericht OP-Bericht
es-AR Spanish (Argentina) nota de intervención quirúrgica:hallazgo:punto en el tiempo:paciente ambulatorio:Documento:{proveedor}
es-MX Spanish (Mexico) Nota de operación quirúrgica:Tipo:Punto temporal:Paciente externo:Documento:{Role}
it-IT Italian (Italy) Nota di operazione chirurgica:Osservazione:Pt:Paziente esterno:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Paziente ambulatoriale;Paziente non ricoverato Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) operatieverslag:bevinding:moment:poliklinisch:document:{rol}
Synonyms: poli
zh-CN Chinese (China) 外科手术记录:发现:时间点:门诊病人: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 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 手术操作记录;外科手术操作记录;手术记录 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 门诊患者

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=34137-0