Version 2.78

59774-0 Procedure anesthesia Narrative

Term Description

The Anesthesia section briefly records the type of anesthesia (e.g., general, conscious, or local) and may state the actual agent(s) used.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Procedure anesthesia
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Anesthesia

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Procedimiento de anestesia:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura anestesia:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ingreep anesthesie:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство анестезия:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作麻醉:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 操作;程序;手续;步骤;规程;程序流程 操作项目麻醉 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

55109-3 Complications Document

Term Description

Information on additional medical problems that develop following a procedure, diagnostic test or study, treatment, or illness.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Complications
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Complications Doc

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
72230-6 Diagnostic imaging report - recommended C-CDA R1.1 sections
81220-6 Diagnostic imaging report - recommended C-CDA R2.0 and R2.1 sections
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
62863-6 PhenX domain - Infectious diseases and immunity
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Complicaciones:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Complicazioni:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) complicaties:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Осложнения:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 并发症:发现:时间点:^患者:文档型:
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 合并症 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

10218-6 Surgical operation note postoperative diagnosis Narrative

Term Description

The Surgical operation note postoperative diagnosis records the diagnosis or diagnoses discovered or confirmed during the surgery. Often it is the same as the pre-operative diagnosis.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Surgical operation note postoperative Dx
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Operative note post-op Dx

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) anotación quirúrgica: diagnóstico posoperatorio:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Nota operatoria postoperatoria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Note opération chirurgicale. Diagnostic postopératoire:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Nota di operazione chirurgica, Dx postoperatoria:Imp:Pt:^Paziente:Nar:
Synonyms: Diagnosi postoperatoria in nota di intervento chir Impressione/interpretazione di studio Nota di intervento chirurgico paziente Procedura chirurgica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag postoperatieve diagnose:interpretatie:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись послеоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Описательный Послеоперационный эпикриз Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录 术后诊断:印象:时间点:^患者:叙述型:
Synonyms: Dx 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 手术操作记录 术后诊断;外科手术操作记录 术后诊断;手术记录 术后诊断;外科手术记录 手术后诊断 手术操作记录;外科手术操作记录;手术记录 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书 诊断（Diagnosis，Dx）

10219-4 Surgical operation note preoperative diagnosis Narrative

Term Description

The Surgical operation note pre-operative diagnosis records the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Surgical operation note preoperative Dx
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Operative note pre-op Dx

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) anotación quirúrgica: diagnóstico preoperatorio:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Nota de operación quirúrgica preoperatoria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Note opération chirurgicale. Diagnostic préopératoire:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Nota di operazione chirurgica, Dx preoperatoria:Imp:Pt:^Paziente:Nar:
Synonyms: Diagnosi preoperatoria in nota di intervento chiru Impressione/interpretazione di studio Nota di intervento chirurgico paziente Procedura chirurgica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag preoperatieve diagnose:interpretatie:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись предоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Описательный Послеоперационный эпикриз Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录术前诊断:印象:时间点:^患者:叙述型:
Synonyms: Dx 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 手术操作记录;外科手术操作记录;手术记录 手术操作记录术前诊断;外科手术操作记录术前诊断;手术记录术前诊断;外科手术记录手术前诊断;外科手术记录-术前诊断;外科手术（外科学手术、外科手术、手术、手术操作）记录术前（手术前、外科手术前、外科学手术前）诊断 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书 诊断（Diagnosis，Dx）

59770-8 Procedure estimated blood loss Narrative

Term Description

Procedure estimated blood loss is the approximate amount of blood that the patient lost during the procedure or surgery. It may be an accurate quantitative amount, e.g., 250 milliliters, or it may be descriptive, e.g., "minimal" or "none".
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Procedure estimated blood loss
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Estimated blood loss

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
6933

Member of these Panels

LOINC Long Common Name
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Procedimiento pérdida de sangre estimada:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura, perdita di sangue stimata:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Perdita di sangue stimata durante procedura Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) bloedverlies ingreep:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство предполагаемая кровопотеря:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作预计失血量:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 失血量;出血;出血量;血液损失 操作;程序;手续;步骤;规程;程序流程 操作项目预计失血量;预计操作项目失血量;预计操作失血量 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 血;全血

59776-5 Procedure findings Narrative

Term Description

The Procedure findings section records clinically significant observations confirmed or discovered during a procedure, treatment or service.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Procedure findings
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Findings

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Hallazgos del procedimiento:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura, osservazioni:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Osservazione Osservazioni su procedura paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ingreep bevindingen:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство находки:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作发现:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 操作;程序;手续;步骤;规程;程序流程 操作项目发现;操作所见;操作项目所见 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

59773-2 Procedure specimens taken Narrative

Term Description

The Procedure specimens taken section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis. The narrative may include a description of the specimens.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Procedure specimens taken
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Specimens taken

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Muestras de procedimiento tomadas:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura, campioni prelevati:Osservazione:Pt:^Paziente:Nar:
Synonyms: Campioni prelevati durante procedura Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ingreep afgenomen monsters:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство образцы изъятые:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Изъятые в ходе вмешательства образцы Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 已采集的操作标本:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 已采集的操作项目标本;已采取的操作标本 操作;程序;手续;步骤;规程;程序流程 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

29554-3 Procedure Narrative

Term Description

Procedure records the descriptions of the procedure with an extensive narrative and may include procedure site preparation, pertinent details related to measurements and markings, procedure times, instrumentation, and vital signs and other monitoring data.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component
Procedure
Property
Type
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Procedure

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.40

Member of these Panels

LOINC Long Common Name
84907-5 Cancer pathology panel - Colorectal cancer specimen
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
82315-3 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 sections
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Prozedur oder Maßnahme:Typ:Zeitpunkt:^Patient:Freitext:
es-ES Spanish (Spain) Procedimiento:Tipo:Punto temporal:^paciente:Narrativo:
es-AR Spanish (Argentina) procedimiento:tipo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Procedimiento:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura:Tipo:Pt:^Paziente:Nar:
Synonyms: Esame obbiettivo paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verrichting:type:moment:^patiënt:tekstueel:
pt-BR Portuguese (Brazil) Procedimento:Tipo:Pt:^Paciente:Nar:
Synonyms: Typ; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Вмешательство:Тип:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作项目:类型:时间点:^患者:叙述型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 型 操作;程序;手续;步骤;规程;程序流程 时刻;随机;随意;瞬间 病史与体格检查

59771-6 Procedure implants Narrative

Term Description

The Procedure implants section records any materials placed during a procedure including stents, tubes, and drains.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Procedure implants
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Implants

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Implantes de procedimiento:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura impianti:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ingreep implantaten:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство импланты:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作植入物:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 操作;程序;手续;步骤;规程;程序流程 操作项目植入物 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

10216-0 Surgical operation note fluids Narrative

Term Description

A record of fluids administered during the surgical procedure.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Surgical operation note fluids
Property
Type
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Operative note fluids

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Líquidos de notas de operación quirúrgica:Tipo:Punto temporal:^ Paciente:Narrativo:
es-AR Spanish (Argentina) anotación quirúrgica: líquidos:tipo:punto en el tiempo:^paciente:Narrativo:
it-IT Italian (Italy) Nota di operazione chirurgica, liquidi:Tipo:Pt:^Paziente:Nar:
Synonyms: Liquidi in nota di intervento chirurgico Nota di intervento chirurgico paziente Procedura chirurgica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag vloeistoffen:type:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись жидкости:Тип:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Послеоперационный эпикриз Послеоперационный эпикриз введенные жидкости Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录 液体:类型:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 型 手术操作记录 液体;外科手术操作记录 液体;手术记录 液体;外科手术记录 输液 手术操作记录;外科手术操作记录;手术记录 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书

10223-6 Surgical operation note surgical procedure Narrative

Term Description

This term may be used to restate the procedures performed, if appropriate, for an enterprise workflow. The procedure(s) performed associated with the Operative note are formally modeled in the header using serviceEvent.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Surgical operation note surgical procedure
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Operative note procedure

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) anotación quirúrgica: procedimiento quirúrgico:hallazgo:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Operación quirúrgica nota procedimiento quirúrgico:Tipo:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Note opération chirurgicale. Procédures chirurgicales:Observation:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Nota di operazione chirurgica, procedura chirurgica:Osservazione:Pt:^Paziente:Nar:
Synonyms: Nota di intervento chirurgico Osservazione paziente Procedura chirurgica Procedura chirurgica in nota di intervento chirurg Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag chirurgische ingreep:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись хирургическое вмешательство:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Послеоперационный эпикриз Процедура Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录 外科手术操作:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 历史纪录与体格检查小节 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 手术操作记录 外科手术操作;外科手术操作记录 外科手术操作;手术记录 外科手术操作;外科手术记录 外科手术操作项目;手术记录 手术操作;外科手术记录 外科手术过程;手术记录 手术过程 手术操作记录;外科手术操作记录;手术记录 操作;程序;手续;步骤;规程;程序流程 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书

18776-5 Plan of care note

Term Description

Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Plan of care note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Plan of care note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 1.0l
Last Updated
Version 2.67
Change Reason
Previous Releases: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.;
Order vs. Observation
Both
HL7® Attachment Structure
IG exists

Member of these Panels

LOINC Long Common Name
57082-0 Antepartum record panel
69459-6 Care record summary panel
72231-4 Consultation note - recommended C-CDA R1.1 sections
81222-2 Consultation note - recommended C-CDA R2.0 and R2.1 sections
72232-2 Continuity of Care Document - recommended C-CDA R1.1 sections
81214-9 Continuity of Care Document - recommended C-CDA R2.0 and R2.1 sections
48769-4 Continuity of Care panel
72229-8 Discharge summary - recommended C-CDA R1.1 sections
81219-8 Discharge summary - recommended C-CDA R2.0 sections
81218-0 Discharge summary - recommended C-CDA R2.1 sections
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72228-0 History and physical note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
82811-1 Nurse summary note - recommended sections
82308-8 Oncology plan of care and summary - recommended CDA R1.2 sections
74293-2 Oncology plan of care and summary - recommended CDA set
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72225-6 Progress note - recommended C-CDA R1.1 sections
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
81614-0 Transfer summary note - recommended C-CDA R2.1 sections

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38745-2 Plan of care note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Behandlungsplan - Notiz:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-AR Spanish (Argentina) plan de tratamiento:hallazgo:punto en el tiempo:plan de tratamiento:Narrativo:
es-MX Spanish (Mexico) Nota del plan de cuidados:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Osservazione Piano di cura Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) behandelplan:bevinding:moment:{instelling}:document:{rol}
Synonyms: zorgplan
zh-CN Chinese (China) 医疗服务计划记录:发现:时间点:{环境}: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 事件发生的地方;场景;环境;背景 医疗服务（照护服务、护理服务、护理、照护、医疗照护、诊疗、诊疗服务、照顾、看护）计划（方案）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 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 笔记;按语;注释;说明;票据;单据;证明书

59772-4 Planned procedure Narrative

Term Description

The Planned Procedure section records the procedure(s) that the clinician thought would be needed based on the pre-procedure assessment.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Planned procedure
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Planned procedure

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Procedimiento planificado:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura prevista:Osservazione:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) geplande ingreep:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Запланированное вмешательство:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 所计划的操作:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 已计划的操作;计划内的操作;所计划的操作项目 操作;程序;手续;步骤;规程;程序流程 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

59775-7 Procedure disposition Narrative

Term Description

The Procedure disposition section records the status and condition of the patient at the completion of the procedure or surgery. It often also states where the patent was transferred to for the next level of care.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Procedure disposition
Property
Find
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Disposition

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Disposición del procedimiento:Tipo:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura, disposizione:Osservazione:Pt:^Paziente:Nar:
Synonyms: Disposizione di procedura Documentazione miscellanea Miscellanea Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ingreep dispositie:bevinding:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство диспозиция:Находка:ТчкВрм:^Пациент:Опис:
Synonyms: Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作处置:发现:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 处理;安排;布置 操作;程序;手续;步骤;规程;程序流程 操作项目处置;操作项目安排;操作安排 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验

59768-2 Procedure indications [Interpretation] Narrative

Term Description

The Procedure indications section records details about the reason for the procedure, treatment or service.
Source: Regenstrief LOINC

Observation Required in Panel

Optional

Fully-Specified Name

Component
Procedure indications
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Procedure indications Imp

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.32
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
87416-4 Diagnostic imaging report - recommended DICOM PS3.20 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
59843-3 Procedure note - recommended C-CDA R1.1 sections
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Indicaciones de procedimiento:Interpretación:Punto temporal:^ Paciente:Narrativo:
it-IT Italian (Italy) Procedura, indicazioni:Imp:Pt:^Paziente:Nar:
Synonyms: Documentazione miscellanea Impressione/interpretazione di studio Indicazioni di procedura Miscellanea paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) indicaties ingreep:interpretatie:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Вмешательство показания:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Описательный Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作适应症:印象:时间点:^患者:叙述型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 操作;程序;手续;步骤;规程;程序流程 操作适应症（适应证、指征）;操作适应症;操作项目适应证 文档.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 适应证;指征;适应症类

11537-8 Surgical drains Narrative

Observation Required in Panel

Optional

Fully-Specified Name

Component
Surgical drains
Property
Find
Time
Pt
System
Surgical procedure
Scale
Nar
Method

Additional Names

Short Name
Surgical drains

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.63

Member of these Panels

LOINC Long Common Name
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) drenajes quirúrgicos:hallazgo:punto en el tiempo:procedimiento quirúrgico:Narrativo:
es-MX Spanish (Mexico) Drenajes quirúrgicos:Tipo:Punto temporal:Procedimiento quirúrgico:Narrativo:
it-IT Italian (Italy) Drenaggio chirurgico:Osservazione:Pt:Procedura chirurgica:Nar:
Synonyms: Clinico Intervento chirurgico Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) chirurgische drains:bevinding:moment:chirurgische ingreep:tekstueel:
pt-BR Portuguese (Brazil) Drenos cirúrgicos:Achado:Pt:Procedimento cirurgico:Nar:
Synonyms: Finding; Findings; Point in time; Random; Narrative; Report
ru-RU Russian (Russian Federation) Хирургические дренажи:Находка:ТчкВрм:Хирургическое вмешательство:Опис:
Synonyms: Описательный Точка во времени;Момент Хирургическая процедура
zh-CN Chinese (China) 外科手术引流:发现:时间点:外科手术操作:叙述型:
Synonyms: 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 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 外科手术;手术过程;外科手术操作项目;外科手术过程;手术;手术操作 外科手术引流管;手术引流管;手术引流 操作;程序;手续;步骤;规程;程序流程 时刻;随机;随意;瞬间