LOINC
Version 2.70

97693-6Interventional radiology 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. Source: HL7

LP57348-2   Interventional radiology
Interventional Radiology is a medical sub-specialty of radiology which utilizes minimally-invasive image-guided procedures to diagnose and treat diseases in nearly every organ system. The concept behind interventional radiology is to diagnose and treat patients using the least invasive techniques currently available in order to minimize risk to the patient and improve health outcomes. Interventional Radiology combines competence in imaging, image-guided minimally invasive procedures, and peri-procedural patient care to diagnose and treat conditions of the thorax (excluding the heart), abdomen, pelvis and extremities. Therapies include embolization, angioplasty, stent placement, thrombus management, drainage and ablation, among others. Source: Regenstrief LOINC

Fully-Specified Name

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

Additional Names

Short Name
IR 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 2.70
Last Updated
Version 2.70
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG39051-4 Interventional radiology|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:介入放射医学
it-ITItalian (Italy)
Nota di operazione chirurgica:Osservazione:Pt:{Setting}:Doc:Radiologia interventistica

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=97693-6