Version 2.74

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
89447-7 Gynecology Hospital Consult note
89446-9 Obstetrics Hospital Consult note

Part Description

LP72311-1   Consultation note
A consultation note is generated by a provider upon request for an opinion or advice from another provider. Consultations may involve face-to-face time with the patient, telemedicine visits, or a second opinion on a diagnosis that does not involve interaction with a patient. A consultation note is typically sent to the referring provider when the consultation is completed. Source: Regenstrief LOINC

Fully-Specified Name

Component
Consultation note
Property
Find
Time
Pt
System
Hospital
Scale
Doc
Method
Obstetrics and Gynecology

Additional Names

Short Name
OBGYN Hosp Consult note

Associated Observations

81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections

This panel contains the recommended sections for consultation 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
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent11348-0 Past medical history R
Indent29545-1 Physical examination R
Indent29299-5 Reason for visit R
Indent42348-3 Advance directives O
Indent48765-2 Allergies O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent10157-6 Family history O
Indent47420-5 Functional status assessment note O
Indent10210-3 General status O
Indent10164-2 History of Present illness Narrative O
Indent11369-6 History of immunizations O
Indent46264-8 History of medical device use O
Indent10160-0 Medications O
Indent10190-7 Mental status Narrative O
Indent61144-2 Diet and nutrition Narrative O
Indent11450-4 Problems O
Indent47519-4 Procedures O
Indent30954-2 Results O
Indent10187-3 Review of systems O
Indent29762-2 Social history O
Indent8716-3 Vital signs O

72231-4 Consultation note - recommended C-CDA R1.1 sections

This panel contains the recommended sections for consultation notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.

LOINC Name R/O/C Cardinality Example UCUM Units
72231-4 Consultation note - recommended C-CDA R1.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent10164-2 History of present illness R
Indent29545-1 Physical examination R
Indent42349-1 Reason for referral R
Indent29299-5 Reason for visit R
Indent48765-2 Allergies O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent10157-6 Family history O
Indent10210-3 General status O
Indent11348-0 Past medical history O
Indent11369-6 History of immunizations O
Indent10160-0 Medications O
Indent11450-4 Problems O
Indent47519-4 Procedures O
Indent30954-2 Results (Diagnostic findings) O
Indent10187-3 Review of systems O
Indent29762-2 Social history O
Indent8716-3 Vital signs O

81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections

This panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).

LOINC Name R/O/C Cardinality Example UCUM Units
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
Indent77599-9 Additional documentation R
Indent77598-1 Externally defined clinical data elements Document R
Indent47420-5 Functional status assessment note R
Indent77597-3 Orders placed Document R
Indent18776-5 Plan of care note R
Indent29762-2 Social history Narrative R
Indent77596-5 Transportation summary Document R
Indent42348-3 Advance directives O
Indent48765-2 Allergies R
Indent51847-2 Evaluation + Plan note R
Indent51848-0 Evaluation note R
Indent46239-0 Chief complaint+Reason for visit Narrative R
Indent10154-3 Chief complaint Narrative - Reported R
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative R
Indent10157-6 History of family member diseases Narrative R
Indent10210-3 Physical findings of General status Narrative R
Indent61146-7 Goals Narrative R
Indent75310-3 Health concerns Document R
Indent11383-7 Patient problem outcome Narrative R
Indent11348-0 History of Past illness Narrative R
Indent10164-2 History of Present illness Narrative R
Indent11369-6 History of Immunization Narrative R
Indent69730-0 Instructions R
Indent62387-6 Interventions Narrative R
Indent46264-8 History of medical device use R
Indent10160-0 History of Medication use Narrative R
Indent10190-7 Mental status Narrative R
Indent61144-2 Diet and nutrition Narrative R
Indent61149-1 Objective Narrative R
Indent48768-6 Payment sources Document R
Indent29545-1 Physical findings Narrative R
Indent11450-4 Problem list - Reported R
Indent47519-4 History of Procedures Document R
Indent42349-1 Reason for referral (narrative) R
Indent29299-5 Reason for visit Narrative R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent10187-3 Review of systems Narrative - Reported R
Indent61150-9 Subjective Narrative R
Indent8716-3 Vital signs R

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.38
Last Updated
Version 2.64
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG38750-2 Consultation note|ANYRole|ANYSetting
LG41829-9 Hospital|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38968-0 Obstetrics and Gynecology|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de consulta:Tipo:Punto temporal:Hospital:Documento:Obstetrics and Gynecology
it-IT Italian (Italy) Nota di consulto:Osservazione:Pt:Ospedale:Doc:Ostetricia e Ginecologia
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) consultverslag:bevinding:moment:ziekenhuis:document:obstetrie en gynaecologie
Synonyms: consultatie-aantekening verloskunde
zh-CN Chinese (China) 会诊记录:发现:时间点:医院: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 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 会诊(咨询、会诊咨询、磋商、商讨会)记录 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 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 病院;院 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=68566-9