Version 2.78

Status Information

Status
DISCOURAGED
Comment
Should specify cervical, lumbar or thoracic
Map-To Long Common Name Mapping Guidance
44114-7 CT Lumbar spine WO and W contrast IT
44113-9 CT Thoracic spine WO and W contrast IT
48450-1 MR Cervical spine WO and W contrast IT

Fully-Specified Name

Component
Multisection^WO & W contrast IT
Property
Find
Time
Pt
System
XXX>Spine
Scale
Doc
Method
CT

Additional Names

Short Name
CT Spine WO+W contr IT

Associated Observations

81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections

This panel contains the recommended sections for diagnostic imaging reports 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
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
Indent11329-0 History general O
Indent55115-0 Request (Radiology) O
Indent55111-9 Current imaging procedure descriptions Document O
Indent55114-3 Prior procedure descriptions O
Indent18834-2 Radiology Comparison study - observation O
Indent18782-3 Radiology Study observation (findings) R
Indent19005-8 Radiology - Impression O
Indent18783-1 Radiology Study recommendation O
Indent55110-1 Conclusions O
Indent55107-7 Addendum O
Indent18785-6 Radiology Reason for study O
Indent55108-5 Patient presentation O
Indent55109-3 Complications O
Indent55112-7 Summary O
Indent55113-5 Key images O

72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections

This panel contains the recommended sections for diagnostic imaging reports 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
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
Indent18782-3 Radiology Study observation (findings) R
Indent55107-7 Addendum O
Indent55108-5 Patient presentation O
Indent55109-3 Complications O
Indent55110-1 Conclusions O
Indent55111-9 Current imaging procedure descriptions Document O
Indent11329-0 History general O
Indent55113-5 Key images O
Indent55114-3 Prior procedure descriptions O
Indent19005-8 Radiology - Impression O
Indent18834-2 Radiology Comparison study - observation O
Indent18785-6 Radiology Reason for study O
Indent18783-1 Radiology Study recommendation O
Indent55115-0 Request (Radiology) O
Indent55112-7 Summary O

Basic Attributes

Class
RAD
Type
Clinical
First Released
Version 2.21
Last Updated
Version 2.61
Change Reason
The scale has been changed from "Nar" to "Doc" to fit with the CDA model.; Per Radlex/LOINC Committee we are changing the order of these components to better reflect the reality of the sequence in which they are performed (first without contrast, then with). Changed System from "Spine" to "XXX>Spine" for conformance with the LOINC/Radlex unified model.
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41853-9 Region imaged: Unspecified (XXX)

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Multisección ^ WO & W contraste IT:Tipo:Punto temporal:XXX> Columna vertebral:Documento:CT
it-IT Italian (Italy) Sezioni multiple^Con & senza contrasto intratecale:Osservazione:Pt:XXX>Colonna vertebrale:Doc:TC
Synonyms: Colonna vertebrale Con e senza contrasto Con e senza contrasto intratecale Multistrato Osservazione Punto nel tempo (episodio) Radiologia Tomografia computerizzata (TC)
pt-BR Portuguese (Brazil) Multi cortes^com e sem contraste IT:Achado:Pt:Coluna:Nar:TC
Synonyms: ; W+WO contr IT; WO contr; W+WO contr IT; Finding; Findings; Point in time; Random; Spinal Cord; Narrative; Report; CAT scan; CT scan; Computerized tomography; Computed tomography; WO & WC; WWO; c; Contrst; Contr; Contra; RADIOLOGY; Imaging; Myelogram
zh-CN Chinese (China) 多层^不采用 & 采用鞘内对比剂:发现:时间点:XXX>脊椎:文档型:CT
Synonyms: (多层（多平面、多切面、多断面、多截面、多剖面、多排） CAT 扫描;CT 扫描;计算机X射线轴向分层造影扫描;计算机X线体层照相术;计算机X线计算机断层摄影术;计算机X线计算机断层照相术;计算机层析X射线成象法;计算机层析X射线摄影术;计算机层析X射线摄影法;计算机层析X射线照相术;计算机层析X射线照相法;计算机层析成象;计算机层析成象术;计算机断层;计算机断层x射线照相法;计算机断层分析;计算机断层成像;计算机断层扫描;计算机断层扫描检查;计算机断层撮影法;计算机断层显像;计算机段层摄影;计算机段层照相术 XXX>脊椎（脊柱、脊骨、椎骨） 不明的;其他;将在相应消息内其他部分之中加以详细说明;未作详细说明的;未作说明的;未做说明的标本;未加规定的;未加说明的标本;杂项 不采用与采用增强剂 IT;不采用与采用对比剂 IT;不采用与采用对比增强剂 IT;不采用与采用鞘内增强剂;不采用与采用鞘内对比增强剂 不采用与采用对比剂;不采用与采用增强剂 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 增强剂 多层（多平面、多切面、多断面、多截面、多剖面、多排）;多排 对比增强剂 成像;放射医学;放射学;显像 时刻;随机;随意;瞬间 脊柱;脊骨;脊髓;椎骨 脊髓像 脊髓成像 脊髓造影 脊髓造影照片 采用和不采用 采用增强剂;采用对比增强剂 采用对比剂 IT 脊髓 采用对比剂 IT;鞘内;鞘内的

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=48442-8