57179-4
Obstetrics and Gynecology Referral note
Discouraged
Status Information
- Status
- DISCOURAGED
- Comment
- The current best practice is to map to the more specific note (i.e. corresponding Obstetric note or Gynecology note) where it is possible.
| Map-To | Long Common Name | Mapping Guidance |
|---|---|---|
| 89225-7 | Gynecology Referral note | |
| 89234-9 | Obstetrics Referral note |
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
- Obstetrics and Gynecology
Additional Names
- Short Name
- OBGYN 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
- Order vs. Observation
- Both
- HL7® Attachment Structure
- Implementation guide exists
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38968-0 | Obstetrics and Gynecology| |
| LG38824-5 | Referral note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de referencia: |
| fr-BE | French (Belgium) | Referral note: Synonyms: Note d''admission |
| it-IT | Italian (Italy) | Nota di rinvio: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) |
| nl-NL | Dutch (Netherlands) | verwijsbrief: Synonyms: verloskunde |
| 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.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=57179-4
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright