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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

LOINC Names Get Info

Fully-Specified Name
Surgical operation note:Find:Pt:{Setting}:Doc:Gynecologic oncology
Long Common Name
Gynecologic Oncology Surgical Operation Note
Short Name
Gyn Onc Operative Note

Part Model Get Info

  • Component
    Surgical operation note
    LP73465-4
    • Analyte
      Surgical operation note
      LP73465-4
      • Component Numerator
        Surgical operation note
        LP73465-4
        • Component Numerator Core
          Surgical operation note
          LP73465-4
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Find
    LP6813-2
  • Time
    Pt
    LP6960-1
  • System
    {Setting}
    LP32887-9
    • System Core
      {Setting}
      LP32887-9
    • Super System
      NULL
       
  • Scale
    Doc
    LP32888-7
  • Method
    Gynecologic oncology
    LP202988-4

Associated Observations

72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections

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.

LOINCNameR/O/CCardinalityExample UCUM Units
72227-2Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
Indent59774-0Procedure anesthesia NarrativeR
Indent55109-3Complications DocumentR
Indent10218-6Surgical operation note postoperative diagnosis NarrativeR
Indent10219-4Surgical operation note preoperative diagnosis NarrativeR
Indent59770-8Procedure estimated blood loss NarrativeR
Indent59776-5Procedure findings NarrativeR
Indent59773-2Procedure specimens taken NarrativeR
Indent29554-3Procedure NarrativeR
Indent59771-6Procedure implants NarrativeO
Indent10216-0Surgical operation note fluids NarrativeO
Indent10223-6Surgical operation note surgical procedure NarrativeO
Indent18776-5Plan of Care NoteO
Indent59772-4Planned procedure NarrativeO
Indent59775-7Procedure disposition NarrativeO
Indent59768-2Procedure indications [Interpretation] NarrativeO
Indent11537-8Surgical drains NarrativeO

81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections

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).

LOINCNameR/O/CCardinalityExample UCUM Units
81241-2Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
Indent77599-9Additional documentationR
Indent77598-1Externally defined clinical data elements DocumentR
Indent77597-3Orders placed DocumentR
Indent18776-5Plan of Care NoteR
Indent59774-0Procedure anesthesia NarrativeR
Indent55109-3Complications DocumentR
Indent46264-8History of medical device useR
Indent10216-0Surgical operation note fluids NarrativeR
Indent10223-6Surgical operation note surgical procedure NarrativeR
Indent48768-6Payment sources DocumentR
Indent59772-4Planned procedure NarrativeR
Indent10218-6Surgical operation note postoperative diagnosis NarrativeR
Indent10219-4Surgical operation note preoperative diagnosis NarrativeR
Indent29554-3Procedure NarrativeR
Indent59775-7Procedure disposition NarrativeR
Indent59770-8Procedure estimated blood loss NarrativeR
Indent59776-5Procedure findings NarrativeR
Indent59771-6Procedure implants NarrativeR
Indent59768-2Procedure indications [Interpretation] NarrativeR
Indent59773-2Procedure specimens taken NarrativeR
Indent11537-8Surgical drains NarrativeR

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.70
Last Updated
Version 2.70 (ADD)
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups Get Info

LOINC GroupGroup Name
LG41826-5{Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG39284-1Gynecologic oncology|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38755-1Surgical operation note|ANYRole|ANYSetting

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Σημείωμα χειρουργικής επέμβασης:Εύρεση:Pt:{Ρυθμίσεις}:Doc:Γυναικολογική ογκολογία
Synonyms: {Ρυθμίσεις} Doc DOC.ONTOLOGY Pt Γυναικολογική ογκολογία Εύρεση Ογκολογία Σημείωμα χειρουργικής επέμβασης Σημείωση
es-MXSpanish (Mexico)Nota de operación quirúrgica:Tipo:Punto temporal:{Configuración}:Documento:Gynecologic oncology
it-ITItalian (Italy)Nota di operazione chirurgica:Osservazione:Pt:{Setting}:Doc:Oncologia ginecologica
Synonyms: Documentazione dell''ontologia Nota di intervento chirurgico Osservazione Punto nel tempo (episodio)
zh-CNChinese (China)外科手术记录:发现:时间点:{环境}:文档型:妇科肿瘤学
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 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 妇癌科 手术操作记录;外科手术操作记录;手术记录 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 笔记;按语;注释;说明;票据;单据;证明书 肿瘤学方法

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=97705-8