81243-8
Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
Active
Term Description
This panel contains the recommended sections for an enhanced encounter 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 |
---|---|---|---|---|
81243-8 | Enhanced encounter 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 | ||
Indent47420-5 | Functional status assessment note | R | ||
Indent77597-3 | Orders placed Document | R | ||
Indent18776-5 | Plan of care note | R | ||
Indent29762-2 | Social history Narrative | R | ||
Indent77596-5 | Transportation summary Document | R | ||
Indent42348-3 | Advance directives | O | ||
Indent48765-2 | Allergies | 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 | ||
Indent46240-8 | History of Hospitalizations+Outpatient visits Narrative | R | ||
Indent10157-6 | History of family member diseases Narrative | R | ||
Indent10210-3 | Physical findings of General status Narrative | R | ||
Indent61146-7 | Goals Narrative | R | ||
Indent75310-3 | Health concerns Document | R | ||
Indent11383-7 | Patient problem outcome Narrative | R | ||
Indent11348-0 | History of Past illness Narrative | R | ||
Indent10164-2 | History of Present illness Narrative | R | ||
Indent11369-6 | History of Immunization Narrative | R | ||
Indent69730-0 | Instructions | R | ||
Indent62387-6 | Interventions Narrative | R | ||
Indent46264-8 | History of medical device use | R | ||
Indent10160-0 | History of Medication use Narrative | R | ||
Indent10190-7 | Mental status Narrative | R | ||
Indent61144-2 | Diet and nutrition Narrative | R | ||
Indent61149-1 | Objective Narrative | R | ||
Indent48768-6 | Payment sources Document | R | ||
Indent29545-1 | Physical findings Narrative | R | ||
Indent11450-4 | Problem list - Reported | R | ||
Indent47519-4 | History of Procedures Document | R | ||
Indent42349-1 | Reason for referral (narrative) | R | ||
Indent29299-5 | Reason for visit Narrative | R | ||
Indent30954-2 | Relevant diagnostic tests/laboratory data Narrative | R | ||
Indent10187-3 | Review of systems Narrative - Reported | R | ||
Indent61150-9 | Subjective Narrative | R | ||
Indent8716-3 | Vital signs | R |
Fully-Specified Name
- Component
- Enhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections
- Property
- -
- Time
- Pt
- System
- {Setting}
- Scale
- -
- Method
Additional Names
- Short Name
- Encd Encounter Nte CDP1 R1.0+1.1
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 encuentro mejorada: |
it-IT | Italian (Italy) | Nota incontro arricchita-sezioni CDP Set 1 R1.0 & R1.1 raccomandate: Synonyms: Panel documentazione Punto nel tempo (episodio) |
zh-CN | Chinese (China) | 增强型就医记录 - 推荐 CDP 集合 1 R1.0 与 R1.1 小节: Synonyms: Ⅰ I 事件发生的地方; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=81243-8 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/81243-8
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright