Version 2.78

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
89226-5 Gynecology Transfer summary note
89235-6 Obstetrics Transfer summary note

Part Description

LP73546-1   Transfer summary note
Transfer summary notes are generated by the originating institution. The setting (when specified) is the facility the patient is being transferred out of (not where they are going). Source: Regenstrief LOINC

Fully-Specified Name

Component
Transfer summary note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Obstetrics and Gynecology

Additional Names

Short Name
OBGYN Transfer sum note

Associated Observations

81614-0 Transfer summary note - recommended C-CDA R2.1 sections

This panel contains the recommended sections for transfer summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
81614-0 Transfer summary note - recommended C-CDA R2.1 sections
Indent48765-2 Allergies R
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent10160-0 History of Medication use Narrative R
Indent11450-4 Problem list - Reported R
Indent42349-1 Reason for referral (narrative) R
Indent30954-2 Results R
Indent8716-3 Vital signs R
Indent46241-6 Hospital admission diagnosis Narrative - Reported O
Indent42346-7 Medications on admission (narrative) O
Indent42348-3 Advance directives O
Indent8648-8 Hospital course Narrative O
Indent11535-2 Hospital discharge Dx Narrative O
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent10210-3 General status 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
Indent48768-6 Payment sources Document O
Indent29545-1 Physical examination O
Indent47519-4 Procedures O
Indent10187-3 Review of systems O
Indent29762-2 Social history O

81221-4 Transfer summary note - recommended C-CDA R2.0 sections

This panel contains the recommended sections for transfer summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.0.

LOINC Name R/O/C Cardinality Example UCUM Units
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
Indent48765-2 Allergies R
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent10160-0 History of Medication use Narrative R
Indent11450-4 Problem list - Reported R
Indent42349-1 Reason for referral (narrative) R
Indent30954-2 Results R
Indent8716-3 Vital signs R
Indent46241-6 Hospital admission diagnosis Narrative - Reported O
Indent42346-7 Medications on admission (narrative) O
Indent42348-3 Advance directives O
Indent8648-8 Hospital course Narrative O
Indent11535-2 Hospital discharge Dx Narrative O
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent10210-3 General status 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
Indent48768-6 Payment sources Document O
Indent29545-1 Physical examination O
Indent47519-4 Procedures O
Indent10187-3 Review of systems O
Indent29762-2 Social history O

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.38
Last Updated
Version 2.64
Change Reason
Updated Component from "Transfer summarization note" to harmonize terms within the existing Document Ontology.
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38968-0 Obstetrics and Gynecology|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38744-5 Transfer summary note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Transferbericht:Ergebnis:Zeitpunkt:{Setting}:Dokument:Frauenheilkunde und Geburtshilfe
Synonyms: Bericht Gynäkologie Transferbericht
es-MX Spanish (Mexico) Transferir nota de resumen:Tipo:Punto temporal:{Configuración}:Documento:Obstetrics and Gynecology
fr-BE French (Belgium) Note résumée de transfert:Observation:Temps ponctuel:{réglages}:Document:Obstétrique et Gynécologie
it-IT Italian (Italy) Traferimento, nota di sintesi:Osservazione:Pt:{Setting}:Doc:Ostetricia e Ginecologia
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) samenvatting van overdracht:bevinding:moment:{instelling}:document:obstetrie en gynaecologie
Synonyms: verloskunde
zh-CN Chinese (China) 移交摘要记录:发现:时间点:{环境}:文档型:产科学与妇科学
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 产科与妇科;妇产科;妇产科学;妇产;女科 产科学方法;产科方法;产科法;产科;助产术 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 妇人科;妇科;妇科医学 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 移交（转移、转送、转介、转院、交接）摘要（小结、概要、总结、梗概、概括、总汇）记录;转院小结记录;转院摘要记录;转院摘要;转院小结;移交摘要;转移摘要记录 移位;转院;转;移交;交接 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=68565-1