Version 2.78

Status Information

Status
DEPRECATED
Reason
Duplicate
Comment
The recommendation is use 34746-8, Nurse Note, to represent a single encounter or 61143-4, Nurse Summary note, to represent an overall nursing summary for a patient as they transition through care. A more specific Nurse note term (where 'Method' contains 'Nurse') may also be appropriate, depending on use-case.
Map-To Long Common Name Mapping Guidance
34746-8 Nurse Note
61143-4 Nurse Summary note

Fully-Specified Name

Component
Nursing notes
Property
Find
Time
-
System
^Patient
Scale
Doc
Method

Additional Names

Long Common Name
Deprecated Nursing notes
Short Name
Deprecated

Basic Attributes

Class
ATTACH.CLINRPT
Type
Claims Attachments
First Released
Version 2.17
Last Updated
Version 2.67

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Note infermieristiche:Osservazione:-:^Paziente:Doc:
Synonyms: Allegato Allegato referto clinico Osservazione paziente
nl-NL Dutch (Netherlands) verpleegkundig verslag:bevinding:-:^patiënt:document:
Synonyms: verslag van verpleging
pt-BR Portuguese (Brazil) Anotações da enfermagem:Achado:-:^Paciente:Doc:
Synonyms: Finding; Findings
ru-RU Russian (Russian Federation) Детская комната записи:Находка:-:^Пациент:Док:
Synonyms: Документ
zh-CN Chinese (China) 护理记录:发现:-:^患者:文档型:
Synonyms: 临床报告信息附件;健康保险便携与责任法案信息附件.临床报告 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 信息附件;健康保险便携与责任法案信息附件;附件 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 护理学记录 记录类;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=46208-5