84268-2Nurse Outpatient Surgical operation noteActive
Part Description
LP73465-4 Surgical operation note
Surgical operation note (Operative note) is note or report created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnoses, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report provides details to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
Source: HL7
Fully-Specified Name
- Component
- Surgical operation note
- Property
- Find
- Time
- Pt
- System
- Outpatient
- Scale
- Doc
- Method
- Nurse
Additional Names
- Short Name
- Nurse OP Operative note
Associated Observations
This panel contains the recommended sections for surgical operation notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 1.1, 2.0 & 2.1.
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 72227-2 | Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections | |||
| Indent59774-0 | Procedure anesthesia Narrative | R | ||
| Indent55109-3 | Complications Document | R | ||
| Indent10218-6 | Surgical operation note postoperative diagnosis Narrative | R | ||
| Indent10219-4 | Surgical operation note preoperative diagnosis Narrative | R | ||
| Indent59770-8 | Procedure estimated blood loss Narrative | R | ||
| Indent59776-5 | Procedure findings Narrative | R | ||
| Indent59773-2 | Procedure specimens taken Narrative | R | ||
| Indent29554-3 | Procedure Narrative | R | ||
| Indent59771-6 | Procedure implants Narrative | O | ||
| Indent10216-0 | Surgical operation note fluids Narrative | O | ||
| Indent10223-6 | Surgical operation note surgical procedure Narrative | O | ||
| Indent18776-5 | Plan of care note | O | ||
| Indent59772-4 | Planned procedure Narrative | O | ||
| Indent59775-7 | Procedure disposition Narrative | O | ||
| Indent59768-2 | Procedure indications [Interpretation] Narrative | O | ||
| Indent11537-8 | Surgical drains Narrative | O |
Associated Observations
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).
| 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 |
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
| LG38952-4 | Nurse| |
| LG41828-1 | Outpatient| |
| LG38755-1 | Surgical operation note| |
Language Variants Get Info
- zh-CNChinese (China)
- 外科手术记录:
发现: 时间点: 门诊病人: 文档型: 护士 - nl-NLDutch (Netherlands)
- operatieverslag:
bevinding: moment: poliklinisch: document: verpleegkundige - de-ATGerman (Austria)
- Operationsbericht:
Ergebnis: Zeitpunkt: ambulant: Dokument: Diplomierte Gesundheits- und Krankenschwester/Diplomierter Gesundheits- und Krankenpfleger - it-ITItalian (Italy)
- Nota di operazione chirurgica:
Osservazione: Pt: Paziente esterno: Doc: Infermiere
LOINC FHIR® API Example - CodeSystem Request Get Info
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=84268-2
LOINC Copyright
Copyright © 2021 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright