Version 2.78

81680-1 Preoperative verification process panel

Term Description

The preoperative verification process includes verifying the patient identity, procedure, and site. The verification process is one of the steps that should be performed prior to any inpatient or outpatient surgery. Multiple organizations have published protocols and/or checklists for prevention of surgical errors, including The Joint Commission (http://www.jointcommission.org/standards_information/up.aspx), the World Health Organization (http://www.who.int/patientsafety/safesurgery/checklist/en/) and the Association of periOperative Registered Nurses
(https://www.aorn.org/guidelines/clinical-resources/tool-kits/correct-site-surgery-tool-kit/aorn-comprehensive-surgical-checklist).
Source: Regenstrief LOINC

Fully-Specified Name

Component
Preoperative verification process panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Additional Names

Short Name
Preop verif process pnl

Basic Attributes

Class
PANEL.SURG
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.63
Order vs. Observation
Subset
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
81679-3 Preoperative measures for patient safety panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Panel de proceso de verificación preoperatoria:-:Punto temporal:^ Paciente:-:
it-IT Italian (Italy) Processo di verifica pre-operatoria panel:-:Pt:^Paziente:-:
Synonyms: Panel di Chirurgia paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 术前核对过程组套:-:时间点:^患者:-:
Synonyms: 医嘱套餐 医嘱套餐类 医嘱套餐组 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 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 时刻;随机;随意;瞬间 术前（手术前、外科手术前、外科学手术前）核对（核实、验证、核查、证实、查对、查清、查证、确证、核验、检验、校验、校核、检定、鉴定、证明、确定）过程组套（组合、医嘱组、套餐、套餐医嘱、医嘱套餐、组合申请、组合项目） 检验医嘱组合类 检验项目医嘱组合类 检验项目组合类 组 组合 组合医嘱 组合类 组套 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）.外科学

81681-9 Verified two types of patient identification

Fully-Specified Name

Component
Verified two types of patient identification
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Verified 2 types pt ID

Basic Attributes

Class
SURG
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.56
Order vs. Observation
Observation

Example Answer List LL4012-2

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
Other, Comment: LA46-8

Member of these Panels

LOINC Long Common Name
81679-3 Preoperative measures for patient safety panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Dos tipos verificados de identificación de pacientes:Tipo:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Identificazione di due tipi di pazienti verificata:Osservazione:Pt:^Paziente:Ord:
Synonyms: Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 已核对两种类型的患者身份标识:发现:时间点:^患者:序数型:
Synonyms: 2 两 依次型;分类顺序型;定性的;序数型（或称等级型）;性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 双 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 已（已经）核对（核实、验证、核查、证实、查对、查清、查证、确证、核验、检验、校验、校核、检定、鉴定、证明、确定）两种类型的患者（病人、病患、病号）身份标识（身份信息、标识信息、身份标识信息） 时刻;随机;随意;瞬间 贰 鉴定;识别;验明;身份证明;确认;认出;核实;认同;身份证件

81682-7 Verified side andor site of procedure

Fully-Specified Name

Component
Verified side &or site of procedure
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Verified proc side +or site

Basic Attributes

Class
SURG
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.56
Order vs. Observation
Observation

Example Answer List LL4012-2

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
Other, Comment: LA46-8

Member of these Panels

LOINC Long Common Name
81679-3 Preoperative measures for patient safety panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Lado verificado y el lugar del procedimiento:Tipo:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Lato &o luogo dell'intervento verificato:Osservazione:Pt:^Paziente:Ord:
Synonyms: Lato e/o luogo dell''intervento verificato Osservazione paziente Posto;Luogo Punto nel tempo (episodio)
zh-CN Chinese (China) 已核对操作项目的偏侧性和或部位:发现:时间点:^患者:序数型:
Synonyms: 位点;位置 依次型;分类顺序型;定性的;序数型（或称等级型）;性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 已（已经）核对（核实、验证、核查、证实、查对、查清、查证、确证、核验、检验、校验、校核、检定、鉴定、证明、确定）的偏侧性（侧面、一边、一侧、一面）和或部位 操作;程序;手续;步骤;规程;程序流程 时刻;随机;随意;瞬间 边;边侧;一侧;一边;侧面

81683-5 Verified procedure

Fully-Specified Name

Component
Verified procedure
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Verified proc

Basic Attributes

Class
SURG
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.56
Order vs. Observation
Observation

Example Answer List LL4012-2

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
Other, Comment: LA46-8

Member of these Panels

LOINC Long Common Name
81679-3 Preoperative measures for patient safety panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Procedimiento verificado:Tipo:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Intervento verificato:Osservazione:Pt:^Paziente:Ord:
Synonyms: Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 已核对操作项目:发现:时间点:^患者:序数型:
Synonyms: 依次型;分类顺序型;定性的;序数型（或称等级型）;性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 已（已经）核对（核实、验证、核查、证实、查对、查清、查证、确证、核验、检验、校验、校核、检定、鉴定、证明、确定）操作项目（操作） 操作;程序;手续;步骤;规程;程序流程 时刻;随机;随意;瞬间

81684-3 Verified patient position

Fully-Specified Name

Component
Verified patient position
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Verified pt position

Basic Attributes

Class
SURG
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.56
Order vs. Observation
Observation

Example Answer List LL4012-2

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
Other, Comment: LA46-8

Member of these Panels

LOINC Long Common Name
81679-3 Preoperative measures for patient safety panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Posición del paciente verificada:Tipo:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Posizione del paziente verificata:Osservazione:Pt:^Paziente:Ord:
Synonyms: Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 已核对患者体位:发现:时间点:^患者:序数型:
Synonyms: 依次型;分类顺序型;定性的;序数型（或称等级型）;性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 姿势;体位;职位;职务;地位;身份 已（已经）核对（核实、验证、核查、证实、查对、查清、查证、确证、核验、检验、校验、校核、检定、鉴定、证明、确定）患者（病人、病患、病号）体位（身体姿势、身体姿态、姿态、姿势） 时刻;随机;随意;瞬间

81685-0 Verified availability of correct implants and any special equipment or requirements

Term Description

Availability of correct implants and any special equipment or special requirements.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Verified availability of correct implants and any special equipment or requirements
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Verified avail implants+special equip

Basic Attributes

Class
SURG
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.56
Order vs. Observation
Observation

Example Answer List LL4012-2

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
Other, Comment: LA46-8

Member of these Panels

LOINC Long Common Name
81679-3 Preoperative measures for patient safety panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Disponibilidad verificada de los implantes correctos y de cualquier equipo o requisito especial:Tipo:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Verificata la disponibilità degli impianti corretti e di quasiasi attrezzatura speciale o richieste:Osservazione:Pt:^Paziente:Ord:
Synonyms: Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 已核对正确的移植物以及任何特殊装备或需求的现成可用性:发现:时间点:^患者:序数型:
Synonyms: 依次型;分类顺序型;定性的;序数型（或称等级型）;性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 已（已经）核对（核实、验证、核查、证实、查对、查清、查证、确证、核验、检验、校验、校核、检定、鉴定、证明、确定）正确的移植物以及任何特殊装备（设备、仪器、仪器设备、仪器装备）或需求（需要、要求）的现成可用性（可用性、有效性、是否可用、可利用性、可利用程度、供应情况、可给性） 时刻;随机;随意;瞬间

81686-8 Performed preoperative time-out assessment

Term Description

The preoperative timeout is one of the steps that should be performed prior to any inpatient or outpatient surgery. The timeout should be conducted in the location where the procedure will be done, just before starting the procedure. It should involve the entire operative team, use active communication, and be briefly documented. Multiple organizations have published protocols and/or checklists for prevention of surgical errors, including The Joint Commission (http://www.jointcommission.org/standards_information/up.aspx), the World Health Organization (http://www.who.int/patientsafety/safesurgery/checklist/en/) and the Association of periOperative Registered Nurses
(https://www.aorn.org/guidelines/clinical-resources/tool-kits/correct-site-surgery-tool-kit/aorn-comprehensive-surgical-checklist).
Source: Regenstrief LOINC

Fully-Specified Name

Component
Performed preoperative time-out assessment
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Perf preop time-out

Basic Attributes

Class
SURG
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.56
Order vs. Observation
Observation

Example Answer List LL4012-2

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
Other, Comment: LA46-8

Member of these Panels

LOINC Long Common Name
81679-3 Preoperative measures for patient safety panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Evaluación del tiempo muerto preoperatorio realizada:Tipo:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Valutazione tempo disponibile pre operatorio eseguito:Osservazione:Pt:^Paziente:Ord:
Synonyms: Osservazione paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 已执行术前暂停评估:发现:时间点:^患者:序数型:
Synonyms: 依次型;分类顺序型;定性的;序数型（或称等级型）;性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 已执行（已完成、已开展、已进行、已行、已做、已检查、已履行）术前（手术前、外科手术前、外科学手术前）暂停评估（评价、评定、判定、评量、核定） 时刻;随机;随意;瞬间 时间(如秒);时间(如秒数) 评价;估计;估价;评论;估定;估算

81687-6 Marked operative site

Term Description

Marking the operative site is one of the steps that should be performed prior to any inpatient or outpatient surgery. Recommendations for marking include making an unambiguous mark (e.g., initials or "YES", not an "X") at or near the incision site, making the mark in a location that is visible after the patient is prepped and draped, and not marking nonoperative sites unless this is necessary for some other aspect of care Multiple organizations have published protocols and/or checklists for prevention of surgical errors, including The Joint Commission (http://www.jointcommission.org/standards_information/up.aspx), the World Health Organization (http://www.who.int/patientsafety/safesurgery/checklist/en/) and the Association of periOperative Registered Nurses (https://www.aorn.org/guidelines/clinical-resources/tool-kits/correct-site-surgery-tool-kit/aorn-comprehensive-surgical-checklist).
Source: Regenstrief LOINC

Fully-Specified Name

Component
Marked operative site
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Marked op site

Basic Attributes

Class
SURG
Type
Clinical
First Released
Version 2.56
Last Updated
Version 2.56
Order vs. Observation
Observation

Example Answer List LL4012-2

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
Other, Comment: LA46-8

Member of these Panels

LOINC Long Common Name
81679-3 Preoperative measures for patient safety panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Sitio operatorio marcado:Tipo:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Luogo preoperatorio indicato:Osservazione:Pt:^Paziente:Ord:
Synonyms: Osservazione paziente Posto;Luogo Punto nel tempo (episodio)
zh-CN Chinese (China) 已标记手术部位:发现:时间点:^患者:序数型:
Synonyms: 位点;位置 依次型;分类顺序型;定性的;序数型（或称等级型）;性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 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 已（已经）标记（标注、标出）手术部位 时刻;随机;随意;瞬间