LOINC
Version 2.71

57057-2Labor and delivery summary noteActive

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

Fully-Specified Name

Component
Labor and delivery summary note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
L&D summary note

Associated Observations

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

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.67
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.; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.
Order vs. Observation
Both

Reference Information

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

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

Language Variants Get Info

zh-CNChinese (China)
临产和分娩摘要记录:发现:时间点:{环境}:文档型:{角色}
de-ATGerman (Austria)
Geburtsbericht (ärztlich):Ergebnis:Zeitpunkt:{Setting}:Dokument:{Typ des Autors}
it-ITItalian (Italy)
Travaglio e parto, sintesi:Osservazione:Pt:{Setting}:Doc:{Role}

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=57057-2