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Status Information

Status
TRIAL

Term Description

This document contains additional documentation captured by the provider related to care provided or planned for the patient that is not supported in any other section of the document. This term was created for, but not limited in use to, the Additional documentation section in the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.

LOINC Names Get Info

Fully-Specified Name
Additional documentation:Find:Pt:{Setting}:Doc:{Role}
Long Common Name
Additional documentation
Short Name
Additional documentation

Part Model Get Info

  • Component
    Additional documentation
    LP192140-4
    • Analyte
      Additional documentation
      LP192140-4
      • Component Numerator
        Additional documentation
        LP192140-4
        • Component Numerator Core
          Additional documentation
          LP192140-4
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Find
    LP6813-2
  • Time
    Pt
    LP6960-1
  • System
    {Setting}
    LP32887-9
    • System Core
      {Setting}
      LP32887-9
    • Super System
      NULL
       
  • Scale
    Doc
    LP32888-7
  • Method
    {Role}
    LP187178-1

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.52
Last Updated
Version 2.63 (MIN)
Change Reason
Previous Releases: 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 Panels

LOINCLong Common Name
81242-0Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
81245-3Interval document - recommended CDP Set 1 R1.0 and R1.1 sections

Language Variants Get Info

TagLanguageTranslation
de-DEGerman (Germany)Ergänzende Dokumentation:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
el-GRGreek (Greece)Πρόσθετη τεκμηρίωση:Εύρεση:Pt:{Ρυθμίσεις}:Doc:{Ρόλος}
Synonyms: {Ρόλος} {Ρυθμίσεις} Doc DOC.MISC MISC Pt Εύρεση Πρόσθετη τεκμηρίωση
es-MXSpanish (Mexico)Documentación adicional:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-ITItalian (Italy)Ulteriore documentazione:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato
zh-CNChinese (China)附加文档记录: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 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.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 未加明确说明的角色 杂项;杂项类;杂项试验 附加文档;附加文件;额外文档记录;其他文档记录 附加的 额外 额外的

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=77599-9