78341-5
Emergency department Transfer summary note
Active
Part Description
LP73546-1 Transfer summary note
Transfer summary notes are generated by the originating institution. The setting (when specified) is the facility the patient is being transferred out of (not where they are going).
Source: Regenstrief LOINC
Fully-Specified Name
- Component
- Transfer summary note
- Property
- Find
- Time
- Pt
- System
- Emergency department
- Scale
- Doc
- Method
- {Role}
Additional Names
- Short Name
- ED Transfer sum note
Associated Observations
81614-0 Transfer summary note - recommended C-CDA R2.1 sections
This panel contains the recommended sections for transfer summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.1.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81614-0 | Transfer summary note - recommended C-CDA R2.1 sections | |||
| Indent48765-2 | Allergies | R | ||
| Indent51847-2 | Assessment+Plan | R | ||
| Indent51848-0 | Assessment | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent10160-0 | History of Medication use Narrative | R | ||
| Indent11450-4 | Problem list - Reported | R | ||
| Indent42349-1 | Reason for referral (narrative) | R | ||
| Indent30954-2 | Results | R | ||
| Indent8716-3 | Vital signs | R | ||
| Indent46241-6 | Hospital admission diagnosis Narrative - Reported | O | ||
| Indent42346-7 | Medications on admission (narrative) | O | ||
| Indent42348-3 | Advance directives | O | ||
| Indent8648-8 | Hospital course Narrative | O | ||
| Indent11535-2 | Hospital discharge Dx Narrative | O | ||
| Indent46240-8 | History of Hospitalizations+Outpatient visits Narrative | O | ||
| Indent10157-6 | History of family member diseases Narrative | O | ||
| Indent47420-5 | Functional status assessment note | O | ||
| Indent10210-3 | General status | O | ||
| Indent11348-0 | History of Past illness Narrative | O | ||
| Indent10164-2 | History of Present illness Narrative | O | ||
| Indent11369-6 | History of Immunization Narrative | O | ||
| Indent46264-8 | History of medical device use | O | ||
| Indent10190-7 | Mental status Narrative | O | ||
| Indent61144-2 | Diet and nutrition Narrative | O | ||
| Indent48768-6 | Payment sources Document | O | ||
| Indent29545-1 | Physical examination | O | ||
| Indent47519-4 | Procedures | O | ||
| Indent10187-3 | Review of systems | O | ||
| Indent29762-2 | Social history | O |
81221-4 Transfer summary note - recommended C-CDA R2.0 sections
This panel contains the recommended sections for transfer summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.0.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81221-4 | Transfer summary note - recommended C-CDA R2.0 sections | |||
| Indent48765-2 | Allergies | R | ||
| Indent51847-2 | Assessment+Plan | R | ||
| Indent51848-0 | Assessment | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent10160-0 | History of Medication use Narrative | R | ||
| Indent11450-4 | Problem list - Reported | R | ||
| Indent42349-1 | Reason for referral (narrative) | R | ||
| Indent30954-2 | Results | R | ||
| Indent8716-3 | Vital signs | R | ||
| Indent46241-6 | Hospital admission diagnosis Narrative - Reported | O | ||
| Indent42346-7 | Medications on admission (narrative) | O | ||
| Indent42348-3 | Advance directives | O | ||
| Indent8648-8 | Hospital course Narrative | O | ||
| Indent11535-2 | Hospital discharge Dx Narrative | O | ||
| Indent46240-8 | History of Hospitalizations+Outpatient visits Narrative | O | ||
| Indent10157-6 | History of family member diseases Narrative | O | ||
| Indent47420-5 | Functional status assessment note | O | ||
| Indent10210-3 | General status | O | ||
| Indent11348-0 | History of Past illness Narrative | O | ||
| Indent10164-2 | History of Present illness Narrative | O | ||
| Indent11369-6 | History of Immunization Narrative | O | ||
| Indent46264-8 | History of medical device use | O | ||
| Indent10190-7 | Mental status Narrative | O | ||
| Indent61144-2 | Diet and nutrition Narrative | O | ||
| Indent48768-6 | Payment sources Document | O | ||
| Indent29545-1 | Physical examination | O | ||
| Indent47519-4 | Procedures | O | ||
| Indent10187-3 | Review of systems | O | ||
| Indent29762-2 | Social history | O |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.54
- Last Updated
- Version 2.58
- 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
- HL7® Attachment Structure
- Implementation guide exists
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41825-7 | Emergency department| |
| LG38744-5 | Transfer summary note| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Transferir nota de resumen: |
| it-IT | Italian (Italy) | Traferimento, nota di sintesi: Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio) Ruolo non specificato |
| nl-NL | Dutch (Netherlands) | samenvatting van overdracht: Synonyms: SEH |
| zh-CN | Chinese (China) | 移交摘要记录: 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.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=78341-5
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright