Version 2.78

Term Description

This document is a concise clinical document that provides an electronic, pre-defined patient health data set applicable both for unexpected, as well as expected (planned), health care contact. This document may be either the product of a medical act or an automatic excerpt from national/regional EHRs.

A Patient Summary gives a healthcare provider the essential information needed for health care coordination and, in cases of an unexpected need or when the patient consults a provider other than his regular contact person (e.g. the general practitioner he/she is registered with), this document enables continuity of care.

Because it is meant to be a summary, this document might not include a detailed medical history, details on clinical conditions or a full list of all prescriptions and dispensed medicines.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Patient summary
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Patient summary Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.34
Last Updated
Version 2.78
Change Reason
Release 2.78: CLASS: Move from Doc.Epsos to support remodeling of concept;

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Patient Summary
de-DE German (Germany) Patientenkurzakte:Befund:Zeitpunkt:^Patient:Dokument:
es-MX Spanish (Mexico) Resumen del paciente:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Profilo sanitario sintetico:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) patiënt samenvatting:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Пациент краткие сведения:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 患者摘要:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 患者（病人、病患、病号）摘要（小结、概要、总结、梗概、概括、总汇） 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=60591-5