Version 2.78

Term Description

This panel contains the recommended sections for an enhanced surgical operation note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).
Source: Regenstrief LOINC

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
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
Indent59774-0 Procedure anesthesia Narrative R
Indent55109-3 Complications Document R
Indent46264-8 History of medical device use R
Indent10216-0 Surgical operation note fluids Narrative R
Indent10223-6 Surgical operation note surgical procedure Narrative R
Indent48768-6 Payment sources Document R
Indent59772-4 Planned procedure Narrative R
Indent10218-6 Surgical operation note postoperative diagnosis Narrative R
Indent10219-4 Surgical operation note preoperative 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
Indent11537-8 Surgical drains Narrative R

Fully-Specified Name

Component
Enhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 sections
Property
-
Time
Pt
System
{Setting}
Scale
-
Method

Additional Names

Short Name
Encd Surg Op Nte CDP1 R1.0+R1.1

Basic Attributes

Class
PANEL.DOC
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.58
Panel Type
Convenience group

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nota de operación quirúrgica mejorada: secciones recomendadas del CDP Set 1 R1.0 y R1.1:-:Punto temporal:{Configuración}:-:
it-IT Italian (Italy) Nota operazione chirurgica arricchita-ezioni CDP Set 1 R1.0& R1.1 raccomandate:-:Pt:{Setting}:-:
Synonyms: Nota di intervento chirurgico Panel documentazione Punto nel tempo (episodio)
zh-CN Chinese (China) 增强型外科手术记录 - 推荐 CDP 集合 1 R1.0 与 R1.1 小节:-:时间点:{环境}:-:
Synonyms: Ⅰ I 事件发生的地方;场景;环境;背景 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 增强型（加强型、改进型）外科手术（外科学手术、外科学手术操作、外科手术操作、手术操作、手术）记录 - 推荐（建议） CDP 集合（集、代码集、取值集合、值集） 1 R1.0 与 R1.1 小节（章节、部分）;HL7 Clinical Documents for Payers;HL7 支付方临床文档;HL7 CDP;美国地域;HL7 临床文档架构;HL7 Clinical Document Architecture;HL7 CDA 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 手术操作记录;外科手术操作记录;手术记录 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

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=81241-2
Questionnaire definition
https://fhir.loinc.org/Questionnaire/?url=http://loinc.org/q/81241-2