LOINC
Version 2.71

89472-5Gynecology Surgical operation noteActive

Part Descriptions

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. Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: HL7, Gynecology (Wikipedia)

LP32899-4   Gynecology
Gynaecology or gynecology (see spelling differences) literally means 'the science of women', but in medicine this is the specialty of diseases of the female reproductive system (uterus, vagina and ovaries). Almost all modern gynaecologists are also obstetricians ; see Obstetrics and gynaecology. Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: Wikipedia, Gynecology (Wikipedia)

LP32899-4   Gynecology
A medical-surgical specialty concerned with the physiology and disorders primarily of the female genital tract, as well as female endocrinology and reproductive physiology. Source: National Library of Medicine, MeSH 2006

Fully-Specified Name

Component
Surgical operation note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Gynecology

Additional Names

Short Name
Gynecology 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 2.64
Last Updated
Version 2.65
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG50065-8 Gynecology|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38755-1 Surgical operation note|ANYRole|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
外科手术记录:发现:时间点:{环境}:文档型:妇科学
nl-NLDutch (Netherlands)
operatieverslag:bevinding:moment:{instelling}:document:gynaecologie
it-ITItalian (Italy)
Nota di operazione chirurgica:Osservazione:Pt:{Setting}:Doc:Ginecologia

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=89472-5