78656-6Radiation oncology procedure noteActive
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
- Radiation oncology
Additional Names
- Short Name
- Radiation Onc Procedure note
Associated Observations
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 |
Associated Observations
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 |
Associated Observations
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
| LG41826-5 | {Setting}| |
| LG38811-2 | Procedure note| |
| LG38990-4 | Radiation oncology| |
Language Variants Get Info
- zh-CNChinese (China)
- 操作记录:
发现: 时间点: {环境}: 文档型: 放射肿瘤学 - nl-NLDutch (Netherlands)
- verslag ingreep:
bevinding: moment: {instelling}: document: radiotherapie - fr-BEFrench (Belgium)
- Note de procédure:
Observation: Temps ponctuel: {réglages}: Document: Irradiation oncologique - it-ITItalian (Italy)
- Procedura, nota:
Osservazione: Pt: {Setting}: Doc: Radioterapia oncologica - es-MXSpanish (Mexico)
- Nota de procedimiento:
Tipo: Punto temporal: {Configuración}: Documento: Radiation oncology
LOINC FHIR® API Example - CodeSystem Request Get Info
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=78656-6
LOINC Copyright
Copyright © 2022 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright