LOINC
Version 2.71

51854-8Long term care facility Consult noteActive

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
Long term care facility
Scale
Doc
Method
{Role}

Additional Names

Short Name
LTC fac Consult note

Associated Observations

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

Associated Observations

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

Associated Observations

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 2.24
Last Updated
Version 2.58
Change Reason
Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Member of these Groups

LG38750-2 Consultation note|ANYRole|ANYSetting
LG41832-3 Long term care facility|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

zh-CNChinese (China)
会诊记录:发现:时间点:长期医疗服务设施:文档型:{角色}
it-ITItalian (Italy)
Nota di consulto:Osservazione:Pt:Struttura di cura a lungo termine:Doc:{Role}

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=51854-8