Version 2.78

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
Oral and maxillofacial surgery

Additional Names

Short Name
OMS Referral note

Associated Observations

81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections

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
Change Reason
Changed Method from Oral surgery to harmonize existing terms in the Document Ontology and per Clinical LOINC Committee approval.
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38983-9 Oral and maxillofacial surgery|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38824-5 Referral note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de referencia:Tipo:Punto temporal:{Configuración}:Documento:Oral and maxillofacial surgery
it-IT Italian (Italy) Nota di rinvio:Osservazione:Pt:{Setting}:Doc:Chirurgia orale e maxillo-facciale
Synonyms: Chirurgia orale e maxillo facciale;chirurgia orale Documentazione dell''ontologia Operazione chirurgica Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verwijsbrief:bevinding:moment:{instelling}:document:oromaxillofaciale chirurgie
zh-CN Chinese (China) 转诊记录:发现:时间点:{环境}:文档型:口腔颌面外科学
Synonyms: 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 口腔与颌面外科学;口腔颌面外科;口腔颌面外科学手术;口腔颌面外科手术;口腔颌面手术 外科;外科手术;手术;手术室 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 笔记;按语;注释;说明;票据;单据;证明书 转诊（转诊介绍、转介、送交、转送、转诊介绍信）记录;转诊介绍记录;转诊介绍信记录

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=57174-5