Version 2.78

Fully-Specified Name

Component
Note
Property
Find
Time
Pt
System
Outpatient
Scale
Doc
Method
General medicine

Additional Names

Short Name
General medicine OP Note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.11
Last Updated
Version 2.50
Change Reason
Component was changed from 'Evaluation and management note' to 'Note' based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that Nursing evaluation and management note, for example, is essentially the same as a Nursing note.
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG38960-7 General medicine|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38748-6 Note|ANYRole|ANYSetting
LG41828-1 Outpatient|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Befund:Ergebnis:Zeitpunkt:ambulant:Dokument:Allgemeinmedizin
Synonyms: Bericht
es-AR Spanish (Argentina) nota de evaluación y manejo:hallazgo:punto en el tiempo:paciente ambulatorio:Documento:medicina general
es-MX Spanish (Mexico) Nota:Tipo:Punto temporal:Paciente externo:Documento:General medicine
it-IT Italian (Italy) Nota:Osservazione:Pt:Paziente esterno:Doc:Medicina generale
Synonyms: Documentazione dell''ontologia Osservazione Paziente ambulatoriale;Paziente non ricoverato Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verslag:bevinding:moment:poliklinisch:document:algemene geneeskunde
Synonyms: huisartsenzorg poli
zh-CN Chinese (China) 记录:发现:时间点:门诊病人:文档型:普通内科学
Synonyms: 一般内科;一般内科学;普通内科;内科 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 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 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=34766-6