77601-3
Enhanced note
Trial
Status Information
- Status
- TRIAL
Term Description
An enhanced note is generated by a provider at the end of an office visit, consult, or home health encounter with a patient. Enhanced encounters may involve face-to-face time with the patient or may fall under the auspices of tele-medicine visits. An enhanced note includes all sections relevant to the specific visit, except for details concerning procedures, operations or imaging performed during the encounter. The document is intended to support the entire contents of the medical record related to a specific encounter with a patient for the administrative or clinical exchange with a third party. This term was created for, but not limited in use to, the Enhanced Encounter Document level template included 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
- Enhanced note:
Find: Pt: {Setting}: Doc: {Role} - Long Common Name
- Enhanced note
- Short Name
- Enhanced note
Part Model Get Info
- Component
- Enhanced note
LP191660-2
- Analyte
- Enhanced note
LP191660-2
- Component Numerator
- Enhanced note
LP191660-2
- Component Numerator Core
- Enhanced note
LP191660-2
- 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
- Time Core
- Pt
LP6960-1
- Time Modifier
- NULL
- System
- {Setting}
LP32887-9
- System Core
- {Setting}
LP32887-9
- Super System
- NULL
- Scale
- Doc
LP32888-7
- Method
- {Role}
LP187178-1
Associated Observations
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 note | R | ||
| Indent77596-5 | Transportation summary Document | R | ||
| Indent42348-3 | Advance Healthcare 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 note | 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 note | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent11369-6 | History of Immunization note | 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 note | 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 note | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R | ||
| Indent61150-9 | Subjective Narrative | R | ||
| Indent8716-3 | Vital signs note | R |
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
- HL7® Attachment Structure
- Implementation guide exists
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| el-GR | Greek (Greece) | Προηγμένο σημείωμα: Synonyms: {Ρόλος} {Ρυθμίσεις} Doc DOC.MISC MISC Pt Εύρεση Προηγμένο σημείωμα Σημείωση |
| es-MX | Spanish (Mexico) | Nota mejorada: |
| it-IT | Italian (Italy) | Nota migliorata: Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| zh-CN | Chinese (China) | 增强型记录: Synonyms: 临床文档型; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
LOINC Copyright
Copyright © Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://