LOINC
Version 2.71

78483-5Neonatal perinatal medicine Referral noteActive

Part Description

LP97117-3   Referral note
A referral note is a note that is sent to a consultant for a consultation (e.g. opinion, testing, etc). This might often be initiated by a primary care provider seeking advice from a specialist while the overall care remains with the PCP. Source: Regenstrief LOINC

Fully-Specified Name

Component
Referral note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Neonatal perinatal medicine

Additional Names

Short Name
Neo peri med Referral note

Associated Observations

This panel contains the recommended sections for referral notes based on 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
81223-0 Referral note - recommended C-CDA R2.0 and R2.1 sections
Indent48765-2 Allergies O
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent10160-0 History of Medication use Narrative O
Indent11450-4 Problem list - Reported O
Indent42349-1 Reason for referral (narrative) O
Indent42348-3 Advance directives O
Indent10157-6 History of family member diseases Narrative O
Indent47420-5 Functional status assessment note O
Indent10210-3 Physical findings of General status Narrative 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
Indent29545-1 Physical examination R
Indent47519-4 Procedures O
Indent30954-2 Results O
Indent10187-3 Review of systems O
Indent29762-2 Social history O
Indent8716-3 Vital signs O

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.54
Last Updated
Version 2.58
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG39007-6 Neonatal perinatal medicine|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38824-5 Referral note|ANYRole|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
转诊记录:发现:时间点:{环境}:文档型:新生儿围产医学
it-ITItalian (Italy)
Nota di rinvio:Osservazione:Pt:{Setting}:Doc:Medicina neonatale perinatale

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=78483-5