84021-5
Surgery Outpatient procedure note
Active
Part Description
LP74249-1 Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure.
Source: HL7
Fully-Specified Name
- Component
- Procedure note
- Property
- Find
- Time
- Pt
- System
- Outpatient
- Scale
- Doc
- Method
- Surgery
Additional Names
- Short Name
- Surgery OP Procedure note
Associated Observations
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
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.
| 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 |
59843-3 Procedure note - recommended C-CDA R1.1 sections
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 Release 1.1.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 59843-3 | Procedure note - recommended C-CDA R1.1 sections | |||
| Indent51847-2 | Assessment+Plan | R | ||
| Indent51848-0 | Assessment | R | ||
| Indent18776-5 | Plan of care | R | ||
| Indent55109-3 | Complications Document | R | ||
| Indent59769-0 | Postprocedure diagnosis Narrative | R | ||
| Indent29554-3 | Procedure description | R | ||
| Indent59768-2 | Procedure indications [Interpretation] Narrative | R | ||
| Indent59770-8 | Procedure estimated blood loss Narrative | O | ||
| Indent59771-6 | Procedure implants Narrative | O | ||
| Indent59772-4 | Planned procedure Narrative | O | ||
| Indent59773-2 | Procedure specimens taken Narrative | O | ||
| Indent59774-0 | Procedure anesthesia Narrative | O | ||
| Indent59775-7 | Procedure disposition Narrative | O | ||
| Indent59776-5 | Procedure findings Narrative | O | ||
| Indent29545-1 | Physical examination | R | ||
| Indent29299-5 | Reason for visit | C | ||
| Indent48765-2 | Allergies | O | ||
| Indent10154-3 | Chief complaint Narrative - Reported | O | ||
| Indent46239-0 | Chief complaint+Reason for visit Narrative | O | ||
| Indent10157-6 | Family history | O | ||
| Indent10210-3 | General status | O | ||
| Indent11348-0 | Past medical history | O | ||
| Indent10160-0 | Medications | O | ||
| Indent29549-3 | Medication administered Narrative | O | ||
| Indent47519-4 | History of Procedures Document | O | ||
| Indent29762-2 | Social history Narrative | O | ||
| Indent10187-3 | Review of systems Narrative - Reported | O |
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
This panel contains the recommended sections for an enhanced procedure note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 81244-6 | Enhanced procedure 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 | ||
| Indent77597-3 | Orders placed Document | R | ||
| Indent18776-5 | Plan of care note | R | ||
| Indent29762-2 | Social history Narrative | R | ||
| Indent48765-2 | Allergies | R | ||
| Indent59774-0 | Procedure anesthesia Narrative | 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 | ||
| Indent55109-3 | Complications Document | R | ||
| Indent10157-6 | History of family member diseases Narrative | R | ||
| Indent11348-0 | History of Past illness Narrative | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent11329-0 | History general Narrative - Reported | R | ||
| Indent46264-8 | History of medical device use | R | ||
| Indent29549-3 | Medication administered Narrative | R | ||
| Indent10160-0 | History of Medication use Narrative | R | ||
| Indent48768-6 | Payment sources Document | R | ||
| Indent29545-1 | Physical findings Narrative | R | ||
| Indent59772-4 | Planned procedure Narrative | R | ||
| Indent59769-0 | Postprocedure 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 | ||
| Indent47519-4 | History of Procedures Document | R | ||
| Indent29299-5 | Reason for visit Narrative | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.58
- 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 |
|---|---|
| LG41828-1 | Outpatient| |
| LG38811-2 | Procedure note| |
| LG38966-4 | Surgery| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de procedimiento: |
| it-IT | Italian (Italy) | Procedura, nota: Synonyms: Documentazione dell''ontologia Nota di procedura Operazione chirurgica Osservazione Paziente ambulatoriale; |
| nl-NL | Dutch (Netherlands) | verslag ingreep: Synonyms: poli verslag procedure |
| zh-CN | Chinese (China) | 操作记录: Synonyms: 临床文档型; |
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=84021-5
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