Version 2.76

Part Description

LP74249-1   Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure. Source: HL7

Fully-Specified Name

Component
Procedure note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Oncology

Additional Names

Short Name
Oncology Procedure note

Associated Observations

81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections

This panel contains the recommended sections for procedure notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent55109-3 Complications Document R
Indent29554-3 Procedure description R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent48765-2 Allergies O
Indent59774-0 Procedure anesthesia Narrative O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent10157-6 Family history O
Indent11348-0 History of Past illness Narrative O
Indent10164-2 History of Present illness Narrative O
Indent11348-0 Past medical history O
Indent29549-3 Medication administered Narrative O
Indent10160-0 Medications O
Indent29545-1 Physical examination O
Indent59772-4 Planned procedure Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59770-8 Procedure estimated blood loss Narrative O
Indent59776-5 Procedure findings Narrative O
Indent59771-6 Procedure implants Narrative O
Indent59773-2 Procedure specimens taken Narrative O
Indent47519-4 History of Procedures Document O
Indent29299-5 Reason for visit O
Indent10187-3 Review of systems Narrative - Reported O
Indent29762-2 Social history Narrative O

59843-3 Procedure note - recommended C-CDA R1.1 sections

This panel contains the recommended sections for procedure notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.

LOINC Name R/O/C Cardinality Example UCUM Units
59843-3 Procedure note - recommended C-CDA R1.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent55109-3 Complications Document R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent29554-3 Procedure description R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent59770-8 Procedure estimated blood loss Narrative O
Indent59771-6 Procedure implants Narrative O
Indent59772-4 Planned procedure Narrative O
Indent59773-2 Procedure specimens taken Narrative O
Indent59774-0 Procedure anesthesia Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59776-5 Procedure findings Narrative O
Indent29545-1 Physical examination R
Indent29299-5 Reason for visit C
Indent48765-2 Allergies O
Indent10154-3 Chief complaint Narrative - Reported O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10157-6 Family history O
Indent10210-3 General status O
Indent11348-0 Past medical history O
Indent10160-0 Medications O
Indent29549-3 Medication administered Narrative O
Indent47519-4 History of Procedures Document O
Indent29762-2 Social history Narrative O
Indent10187-3 Review of systems Narrative - Reported O

81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections

This panel contains the recommended sections for an enhanced procedure 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
81244-6 Enhanced procedure 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
Indent77597-3 Orders placed Document R
Indent18776-5 Plan of care note R
Indent29762-2 Social history Narrative R
Indent48765-2 Allergies R
Indent59774-0 Procedure anesthesia Narrative 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
Indent55109-3 Complications Document R
Indent10157-6 History of family member diseases Narrative R
Indent11348-0 History of Past illness Narrative R
Indent10164-2 History of Present illness Narrative R
Indent11329-0 History general Narrative - Reported R
Indent46264-8 History of medical device use R
Indent29549-3 Medication administered Narrative R
Indent10160-0 History of Medication use Narrative R
Indent48768-6 Payment sources Document R
Indent29545-1 Physical findings Narrative R
Indent59772-4 Planned procedure Narrative R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent29554-3 Procedure Narrative R
Indent59775-7 Procedure disposition Narrative R
Indent59770-8 Procedure estimated blood loss Narrative R
Indent59776-5 Procedure findings Narrative R
Indent59771-6 Procedure implants Narrative R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent59773-2 Procedure specimens taken Narrative R
Indent47519-4 History of Procedures Document R
Indent29299-5 Reason for visit Narrative R
Indent10187-3 Review of systems Narrative - Reported R

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.58
Last Updated
Version 2.58
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38980-5 Oncology|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38811-2 Procedure note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de procedimiento:Tipo:Punto temporal:{Configuración}:Documento:Oncology
fr-BE French (Belgium) Note de procédure:Observation:Temps ponctuel:{réglages}:Document:Oncologie
it-IT Italian (Italy) Procedura, nota:Osservazione:Pt:{Setting}:Doc:Oncologia
Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verslag ingreep:bevinding:moment:{instelling}:document:oncologie
Synonyms: verslag procedure
zh-CN Chinese (China) 操作记录:发现:时间点:{环境}:文档型:肿瘤学
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 操作;程序;手续;步骤;规程;程序流程 操作项目记录 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 笔记;按语;注释;说明;票据;单据;证明书 肿瘤学方法

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=78478-5