Version 2.78

Fully-Specified Name

Component
Plan of care note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Thoracic and cardiac surgery

Additional Names

Short Name
Cardiothor surg Plan of care note

Associated Observations

81215-6 Care plan - recommended C-CDA R2.0 and R2.1 sections

This panel contains the recommended sections for a care plan note 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
81215-6 Care plan - recommended C-CDA R2.0 and R2.1 sections
Indent61146-7 Goals Narrative R
Indent75310-3 Health concerns Document R
Indent11383-7 Patient problem outcome Narrative O
Indent62387-6 Interventions Narrative O

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.56
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
LG38745-2 Plan of care note|ANYRole|ANYSetting
LG38997-9 Thoracic and cardiac surgery|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota del plan de cuidados:Tipo:Punto temporal:{Configuración}:Documento:Thoracic and cardiac surgery
it-IT Italian (Italy) Piano di cura, nota:Osservazione:Pt:{Setting}:Doc:Chirurgia toracica
Synonyms: Chirurgia cardiotoracica Documentazione dell''ontologia Operazione chirurgica Osservazione Piano di cura Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) behandelplan:bevinding:moment:{instelling}:document:cardiothoracale chirurgie
Synonyms: zorgplan
zh-CN Chinese (China) 医疗服务计划记录:发现:时间点:{环境}:文档型:胸心外科学
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 医疗服务（照护服务、护理服务、护理、照护、医疗照护、诊疗、诊疗服务、照顾、看护）计划（方案）记录 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 外科;外科手术;手术;手术室 心胸外科学;胸外科学;心胸外科;心胸外;胸心外科;胸心外 心脏外科;心脏外;心外;心脏外科学手术;心脏外科手术;心脏手术;心脏外科学（心脏外科学手术、心脏外科、心脏外、心外、心脏外科手术、心脏手术） 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

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=80749-5