Version 2.78

Fully-Specified Name

Component
Postoperative evaluation and management note
Property
Find
Time
Pt
System
Hospital
Scale
Doc
Method
{Role}

Additional Names

Short Name
Hosp Post-op E/M note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.38
Last Updated
Version 2.54
Change Reason
Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG41829-9 Hospital|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38761-9 Postoperative evaluation and management note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Evaluación postoperatoria y nota de manejo:Tipo:Punto temporal:Hospital:Documento:{Role}
it-IT Italian (Italy) Nota di gestione e valutazione post operatoria:Osservazione:Pt:Ospedale:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di valutazione e gestione Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) postoperatief onderzoeks- en voortgangsverslag:bevinding:moment:ziekenhuis:document:{rol}
zh-CN Chinese (China) 术后评价与管理记录:发现:时间点:医院:文档型:{角色}
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 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 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 未加明确说明的角色 术后（手术后、外科手术后、外科学手术后）评价（评估、测评、评测、评判、评定、判定、评量、核定）与管理记录;手术后评价与管理记录;术后评估与管理记录 病院;院 笔记;按语;注释;说明;票据;单据;证明书 评价（评估、测评、评测、评判、评定、判定、评量、核定）与管理记录 评估 评定 鉴定

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=68610-5