LOINC
Version 2.71

57145-5Neurology Referral noteActive

Part Description

LP97117-3   Referral note
A referral note is a note that is sent to a consultant for a consultation (e.g. opinion, testing, etc). This might often be initiated by a primary care provider seeking advice from a specialist while the overall care remains with the PCP. Source: Regenstrief LOINC

Fully-Specified Name

Component
Referral note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Neurology

Additional Names

Short Name
Neurology Referral note

Associated Observations

This panel contains the recommended sections for referral 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
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
Indent48765-2 Allergies O
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent10160-0 History of Medication use Narrative O
Indent11450-4 Problem list - Reported O
Indent42349-1 Reason for referral (narrative) O
Indent42348-3 Advance directives O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent10210-3 Physical findings of General status Narrative O
Indent11348-0 History of Past illness Narrative O
Indent10164-2 History of Present illness Narrative O
Indent11369-6 History of Immunization Narrative O
Indent46264-8 History of medical device use O
Indent10190-7 Mental status Narrative O
Indent61144-2 Diet and nutrition Narrative O
Indent29545-1 Physical examination R
Indent47519-4 Procedures O
Indent30954-2 Results O
Indent10187-3 Review of systems O
Indent29762-2 Social history O
Indent8716-3 Vital signs O

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.67
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38976-3 Neurology|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38824-5 Referral note|ANYRole|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
转诊记录:发现:时间点:{环境}:文档型:神经病学
nl-NLDutch (Netherlands)
verwijsbrief:bevinding:moment:{instelling}:document:neurologie
fr-BEFrench (Belgium)
Referral note:Observation:Temps ponctuel:{réglages}:Document:Neurologie
it-ITItalian (Italy)
Nota di rinvio:Osservazione:Pt:{Setting}:Doc:Neurologia

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=57145-5