57175-2
Orthopaedic Surgery Referral Note
Active
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
LOINC Names Get Info
- Fully-Specified Name
- Referral note:
Find: Pt: {Setting}: Doc: Orthopaedic surgery - Long Common Name
- Orthopaedic Surgery Referral Note
- Short Name
- Orthopaedic Surgery Referral Note
Part Model Get Info
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 Healthcare Directives | O | ||
| Indent10157-6 | History of family member diseases note | O | ||
| Indent47420-5 | Functional Status Assessment Note | O | ||
| Indent10210-3 | Physical findings of General status Narrative | O | ||
| Indent11348-0 | History of Past illness note | O | ||
| Indent10164-2 | History of Present illness Narrative | O | ||
| Indent11369-6 | History of Immunization note | 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 (MIN)
- Change Reason
- Changed spelling of 'Orthopedic' to 'Orthopaedic' per Clinical LOINC Committee and to harmonize with ABMS.
- Order vs. Observation
- Both
- HL7® Attachment Structure
- Implementation guide exists
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38984-7 | Orthopaedic surgery| |
| LG38824-5 | Referral note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| el-GR | Greek (Greece) | Παραπεμπτικό σημείωμα: Synonyms: {Ρυθμίσεις} Doc DOC.ONTOLOGY Pt Εύρεση Ορθοπεδική χειρουργική Παραπεμπτικό σημείωμα Σημείωση Χειρουργική επέμβαση |
| es-MX | Spanish (Mexico) | Nota de referencia: |
| it-IT | Italian (Italy) | Nota di rinvio: Synonyms: Documentazione dell''ontologia Operazione chirurgica Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verwijsbrief: Synonyms: orthopedie |
| zh-CN | Chinese (China) | 转诊记录: Synonyms: 临床文档型; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
LOINC Copyright
Copyright © Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://