Version 2.78

Fully-Specified Name

Component
Interventional procedure note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Cardiovascular disease

Additional Names

Short Name
Cardiology Interv proced note

Associated Observations

81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections

This panel contains the recommended sections for procedure notes 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
81217-2 Procedure 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
Indent55109-3 Complications Document R
Indent29554-3 Procedure description R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent48765-2 Allergies O
Indent59774-0 Procedure anesthesia Narrative O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent10157-6 Family history O
Indent11348-0 History of Past illness Narrative O
Indent10164-2 History of Present illness Narrative O
Indent11348-0 Past medical history O
Indent29549-3 Medication administered Narrative O
Indent10160-0 Medications O
Indent29545-1 Physical examination O
Indent59772-4 Planned procedure Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59770-8 Procedure estimated blood loss Narrative O
Indent59776-5 Procedure findings Narrative O
Indent59771-6 Procedure implants Narrative O
Indent59773-2 Procedure specimens taken Narrative O
Indent47519-4 History of Procedures Document O
Indent29299-5 Reason for visit O
Indent10187-3 Review of systems Narrative - Reported O
Indent29762-2 Social history Narrative O

59843-3 Procedure note - recommended C-CDA R1.1 sections

This panel contains the recommended sections for procedure 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
59843-3 Procedure note - recommended C-CDA R1.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent55109-3 Complications Document R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent29554-3 Procedure description R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent59770-8 Procedure estimated blood loss Narrative O
Indent59771-6 Procedure implants Narrative O
Indent59772-4 Planned procedure Narrative O
Indent59773-2 Procedure specimens taken Narrative O
Indent59774-0 Procedure anesthesia Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59776-5 Procedure findings Narrative O
Indent29545-1 Physical examination R
Indent29299-5 Reason for visit C
Indent48765-2 Allergies O
Indent10154-3 Chief complaint Narrative - Reported O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10157-6 Family history O
Indent10210-3 General status O
Indent11348-0 Past medical history O
Indent10160-0 Medications O
Indent29549-3 Medication administered Narrative O
Indent47519-4 History of Procedures Document O
Indent29762-2 Social history Narrative O
Indent10187-3 Review of systems Narrative - Reported O

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.11
Last Updated
Version 2.58
Change Reason
Changed Method of 'Cardiology' to 'Cardiovascular disease'. Edits based on Clinical LOINC Committee approval at 1/20/2011 meeting to harmonize existing terms with Document Ontology values.
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38954-0 Cardiovascular disease|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38763-5 Interventional procedure note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) INTERVENTIONAL PROCEDURE NOTE:hallazgo:punto en el tiempo:{contexto}:Documento:cardiología
es-MX Spanish (Mexico) Nota de procedimiento intervencionista:Tipo:Punto temporal:{Configuración}:Documento:Cardiovascular disease
fr-BE French (Belgium) Note procédure interventions:Observation:Temps ponctuel:{réglages}:Document:Maladies cardiovasculaires
it-IT Italian (Italy) Procedura interventistica, nota:Osservazione:Pt:{Setting}:Doc:Malattia cardiovascolare
Synonyms: Documentazione dell''ontologia Nota di procedura Nota di procedura interventistica Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verslag interventieprocedure:bevinding:moment:{instelling}:document:cardiovasculaire aandoening
Synonyms: verslag procedure
zh-CN Chinese (China) 干预性操作记录:发现:时间点:{环境}:文档型:心血管疾病
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 干预性（干预）操作（操作项目）记录 心血管病 操作;程序;手续;步骤;规程;程序流程 操作项目记录 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 疾 病 症 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=34896-1