Version 2.78

Term Description

The eNursing Summary contains data sets related to specific clinical enviroment as a process to create safe, effective communication, ensuring continuity as the patient moves through care transitions. Transitions, or "hand-offs", occur multiple times each day in a hospital and at every change of care location.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Summary note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Nurse

Additional Names

Short Name
Nurse Summary note

Associated Observations

82811-1 Nurse summary note - recommended sections

LOINC Name R/O/C Cardinality Example UCUM Units
82811-1 Nurse summary note - recommended sections
Indent48765-2 Allergies and other adverse reactions O
Indent42348-3 Coded advanced directives O
Indent51848-0 Assessment O
Indent11332-4 Hx of cognitive function O
Indent11450-4 Active problems O
Indent10154-3 Chief complaint Narrative - Reported O
Indent46241-6 Hospital adm diagnosis O
Indent11535-2 Discharge diagnosis O
Indent46264-8 Medical devices O
Indent30954-2 Coded results O
Indent18610-6 Medications (administered) O
Indent47519-4 Procedures and interventions O
Indent38212-7 Pain assessment panel O
Indent46209-3 Provider orders O
Indent18776-5 Treatment plan O
Indent8716-3 Vital signs O
Indent61144-2 Diet and nutrition Narrative O
Indent61148-3 Fluid management note O

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.34
Last Updated
Version 2.67
Change Reason
Previous Releases: Changed system from '^Patient' to represent current LOINC Document Ontology model.; Removed children and added them to associated oberservation panel 82811-1;
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38952-4 Nurse|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38844-3 Summary note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota resumida:Tipo:Punto temporal:{Configuración}:Documento:Nurse
it-IT Italian (Italy) Nota di sintesi:Osservazione:Pt:{Setting}:Doc:Infermiere
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) samenvatting:bevinding:moment:{instelling}:document:verpleegkundige
zh-CN Chinese (China) 摘要:发现:时间点:{环境}:文档型:护士
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 保护者 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 小结;概要;概括;总汇;总结 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

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=61143-4