Version 2.74

Term Description

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.
Source: Regenstrief LOINC

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

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

Fully-Specified Name

Procedure note - recommended C-CDA R2.0 & R2.1 sections

Additional Names

Short Name
Proced Nte C-CDA R2.0+2.1 Sections

Basic Attributes

First Released
Version 2.56
Last Updated
Version 2.56
Panel Type
Convenience group

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de procedimiento: secciones recomendadas de C-CDA R2.0 y R2.1:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Intervento nota- sezioniC-CDA R2.0 & R2.1 raccomandate:-:Pt:{Setting}:-:
Synonyms: Nota di procedura Panel documentazione Punto nel tempo (episodio)
zh-CN Chinese (China) 操作记录 - 推荐 C-CDA R2.0 与 R2.1 小节:-:时间点:{环境}:-:
Synonyms: C 型;丙;丙型 事件发生的地方;场景;环境;背景 先天性红细胞生成异常性贫血 先天性红细胞生成异常性贫血(Congenital dyserythropoietic anaemia,CDA) 先天性红细胞生成障碍性贫血 先天性红血球生成不良性贫血 医嘱套餐 医嘱套餐类 医嘱套餐组 医嘱组 医嘱组.文档;文书组套(组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目);文件医嘱组;医疗文书医嘱组;医疗文件医嘱组 医嘱组合 医嘱组合类 医嘱组套 医嘱组套类 医嘱组类 多重;多重型;多重标尺类型;多重精度类型 套餐 套餐医嘱 套餐医嘱组 套餐医嘱组类 实验室医嘱套餐 实验室医嘱套餐类 实验室医嘱组 实验室医嘱组合类 实验室医嘱组套 实验室医嘱组套类 实验室套餐医嘱组 实验室套餐医嘱组类 实验室检验项目医嘱组合类 实验室检验项目组合类 操作(操作项目)记录 - 推荐(建议) C-CDA R2.0 与 R2.1 小节(章节、部分);Consolidated-Clinical Document Architecture;联合临床文档架构;统一临床文档架构;C-CDA;HL7 临床文档架构;HL7 Clinical Document Architecture;HL7 CDA 操作;程序;手续;步骤;规程;程序流程 操作项目记录 时刻;随机;随意;瞬间 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 笔记;按语;注释;说明;票据;单据;证明书 组 组合 组合医嘱 组合类 组套

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