Version 2.77

Term Description

A labor and delivery summary (LDS) document represents a summary of the most critical information concerning the labor and delivery care in a birthing facility.
Source: Regenstrief LOINC

Reference Information

Type Source Reference
Webcontent Integrating the Healthcare EnterpriseCopyright Copyright © 2009 IHE International.

Fully-Specified Name

Labor and delivery summary note

Additional Names

Short Name
L&D summary note

Associated Observations

92574-3 Labor and delivery summary - recommended IHE set

The recommended set of terms to be used within a Labor and delivery summaryl note [LOINC: 57057-2] based on the IHE Labor and Delivery Admission History and Physical (LDHP) profile. The LDS represents a summary of the most critical information concerning the labor and delivery care in a birthing facility.

LOINC Name R/O/C Cardinality Example UCUM Units
92574-3 Labor and delivery summary - recommended IHE set
Indent46241-6 Hospital admission diagnosis
Indent10154-3 Chief complaint
Indent11459-5 Transport mode
Indent10160-0 Admission medication history
Indent51847-2 Assessment and plan
Indent30954-2 Coded results
Indent10164-2 History of present illness
Indent11348-0 History of past illness
Indent56838-6 Coded history of infection
Indent42348-3 Coded advanced directives
Indent57079-6 Birth plan
Indent48765-2 Allergies and other adverse reactions
Indent29545-1 Coded physical exam
Indent10162-6 Pregnancy history
Indent57060-6 Estimated delivery dates
Indent29762-2 Coded social history
Indent18610-6 Medications administered
Indent57072-1 Intravenous fluids administered
Indent57073-9 Prenatal events
Indent10167-5 List of surgeries
Indent57074-7 Labor and delivery process
Indent57075-4 Newborn delivery information
Indent55103-6 Estimated blood loss
Indent57078-8 Coded antenatal testing and surveillance

Basic Attributes

First Released
Version 2.29
Last Updated
Version 2.67
Change Reason
Previous Releases: 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

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Geburtsbericht (ärztlich):Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}
Synonyms: Bericht
es-MX Spanish (Mexico) Nota resumen de trabajo y parto:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Travaglio e parto, nota di sintesi:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di sintesi relativa a travaglio e parto Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) samenvatting zwangerschap en geboorte:bevinding:moment:{instelling}:document:{rol}
zh-CN Chinese (China) 临产和分娩摘要记录:发现:时间点:{环境}:文档型:{角色}
Synonyms: 临产(阵痛)和分娩摘要(小结、概要、总结、梗概、概括、总汇)记录;临产和分娩小结记录;阵痛和分娩摘要记录;分娩摘要记录 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 小结;概要;概括;总汇;总结 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 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书

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