34822-7
Physical medicine and rehab Consult note
Active
Part Description
LP72311-1 Consultation note
A consultation note is generated by a provider upon request for an opinion or advice from another provider. Consultations may involve face-to-face time with the patient, telemedicine visits, or a second opinion on a diagnosis that does not involve interaction with a patient. A consultation note is typically sent to the referring provider when the consultation is completed.
Source: Regenstrief LOINC
Fully-Specified Name
- Component
- Consultation note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Physical medicine and rehab
Additional Names
- Short Name
- PM+R Consult note
Associated Observations
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
This panel contains the recommended sections for consultation notes based on 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 |
|---|---|---|---|---|
| 81222-2 | Consultation 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 | ||
| Indent11348-0 | Past medical history | R | ||
| Indent29545-1 | Physical examination | R | ||
| Indent29299-5 | Reason for visit | R | ||
| Indent42348-3 | Advance directives | O | ||
| Indent48765-2 | Allergies | O | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | O | ||
| Indent10154-3 | Chief complaint Narrative - Reported | O | ||
| Indent10157-6 | Family history | O | ||
| Indent47420-5 | Functional status assessment note | O | ||
| Indent10210-3 | General status | O | ||
| Indent10164-2 | History of Present illness Narrative | O | ||
| Indent11369-6 | History of immunizations | O | ||
| Indent46264-8 | History of medical device use | O | ||
| Indent10160-0 | Medications | O | ||
| Indent10190-7 | Mental status Narrative | O | ||
| Indent61144-2 | Diet and nutrition Narrative | O | ||
| Indent11450-4 | Problems | O | ||
| Indent47519-4 | Procedures | O | ||
| Indent30954-2 | Results | O | ||
| Indent10187-3 | Review of systems | O | ||
| Indent29762-2 | Social history | O | ||
| Indent8716-3 | Vital signs | O |
72231-4 Consultation note - recommended C-CDA R1.1 sections
This panel contains the recommended sections for consultation 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 |
|---|---|---|---|---|
| 72231-4 | Consultation note - recommended C-CDA R1.1 sections | |||
| Indent51847-2 | Assessment+Plan | R | ||
| Indent51848-0 | Assessment | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent10164-2 | History of present illness | R | ||
| Indent29545-1 | Physical examination | R | ||
| Indent42349-1 | Reason for referral | R | ||
| Indent29299-5 | Reason for visit | R | ||
| Indent48765-2 | Allergies | O | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | O | ||
| Indent10154-3 | Chief complaint Narrative - Reported | O | ||
| Indent10157-6 | Family history | O | ||
| Indent10210-3 | General status | O | ||
| Indent11348-0 | Past medical history | O | ||
| Indent11369-6 | History of immunizations | O | ||
| Indent10160-0 | Medications | O | ||
| Indent11450-4 | Problems | O | ||
| Indent47519-4 | Procedures | O | ||
| Indent30954-2 | Results (Diagnostic findings) | O | ||
| Indent10187-3 | Review of systems | O | ||
| Indent29762-2 | Social history | O | ||
| Indent8716-3 | Vital signs | O |
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
This panel contains the recommended sections for an enhanced encounter 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 |
|---|---|---|---|---|
| 81243-8 | Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections | |||
| Indent77599-9 | Additional documentation | R | ||
| Indent77598-1 | Externally defined clinical data elements Document | R | ||
| Indent47420-5 | Functional status assessment note | R | ||
| Indent77597-3 | Orders placed Document | R | ||
| Indent18776-5 | Plan of care note | R | ||
| Indent29762-2 | Social history Narrative | R | ||
| Indent77596-5 | Transportation summary Document | R | ||
| Indent42348-3 | Advance directives | O | ||
| Indent48765-2 | Allergies | R | ||
| Indent51847-2 | Evaluation + Plan note | R | ||
| Indent51848-0 | Evaluation note | R | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | R | ||
| Indent10154-3 | Chief complaint Narrative - Reported | R | ||
| Indent46240-8 | History of Hospitalizations+Outpatient visits Narrative | R | ||
| Indent10157-6 | History of family member diseases Narrative | R | ||
| Indent10210-3 | Physical findings of General status Narrative | R | ||
| Indent61146-7 | Goals Narrative | R | ||
| Indent75310-3 | Health concerns Document | R | ||
| Indent11383-7 | Patient problem outcome Narrative | R | ||
| Indent11348-0 | History of Past illness Narrative | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent11369-6 | History of Immunization Narrative | R | ||
| Indent69730-0 | Instructions | R | ||
| Indent62387-6 | Interventions Narrative | R | ||
| Indent46264-8 | History of medical device use | R | ||
| Indent10160-0 | History of Medication use Narrative | R | ||
| Indent10190-7 | Mental status Narrative | R | ||
| Indent61144-2 | Diet and nutrition Narrative | R | ||
| Indent61149-1 | Objective Narrative | R | ||
| Indent48768-6 | Payment sources Document | R | ||
| Indent29545-1 | Physical findings Narrative | R | ||
| Indent11450-4 | Problem list - Reported | R | ||
| Indent47519-4 | History of Procedures Document | R | ||
| Indent42349-1 | Reason for referral (narrative) | R | ||
| Indent29299-5 | Reason for visit Narrative | R | ||
| Indent30954-2 | Relevant diagnostic tests/laboratory data Narrative | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R | ||
| Indent61150-9 | Subjective Narrative | R | ||
| Indent8716-3 | Vital signs | R |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.11
- Last Updated
- Version 2.58
- Change Reason
- Shortened Method from "Physical medicine and rehabilitation" to "Physical medicine and rehab" in order to allow for space in the Method field for Role attributes e.g. "Physical medicine and rehab.physician attending".
- Order vs. Observation
- Both
- HL7® Attachment Structure
- Implementation guide exists
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38750-2 | Consultation note| |
| LG38987-0 | Physical medicine and rehab| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| de-AT | German (Austria) | Synonyms: Physikalisch-Medizinischer Befund |
| es-AR | Spanish (Argentina) | medicina física y rehabilitación: |
| es-MX | Spanish (Mexico) | Nota de consulta: |
| it-IT | Italian (Italy) | Nota di consulto: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 会诊记录: Synonyms: 临床文档型; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=34822-7
LOINC Copyright
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