LOINC
Version 2.71

61143-4Nurse Summary noteActive

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

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
Changed system from '^Patient' to represent current LOINC Document Ontology model.; Removed children and added them to associated oberservation panel 82811-1; Because it is too difficult to maintain and because the distinction between documents and sections is not clear-cut nor necessary in most cases, the DOCUMENT_SECTION field has been deemed to have little value. The field has been set to null in the December 2017 release in preparation for removal in the December 2018 release. These changes were approved by the Clinical LOINC Committee.
Order vs. Observation
Both

Member of these Groups

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

Language Variants Get Info

zh-CNChinese (China)
摘要:发现:时间点:{环境}:文档型:护士
nl-NLDutch (Netherlands)
samenvatting:bevinding:moment:{instelling}:document:verpleegkundige
it-ITItalian (Italy)
Nota di sintesi:Osservazione:Pt:{Setting}:Doc:Infermiere

LOINC FHIR® API Example - CodeSystem Request Get Info

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