6.3 Document type codes

In the following subsections, synonymy or equivalent terms are designated by parenthesis. Document codes are defined by their component Parts. The first list of axis values was published in 2003, and served as the basis for an initial set of LOINC codes.

Through both empiric analysis and expert review, we have continued evaluating and refining this list. The following listing contains the current set of axis values for the elements of document type codes that have been vetted by the LOINC Committee. We are in the process of carefully harmonizing our existing Document terms with these new values.

6.3.1 Kind of Document

Characterizes the purpose or structure of the document, section, or entry. Examples include flowsheet, discharge plan, consent, surgical report.

6.3.1.1 LOINC’s use of “Note” versus “Report”

In LOINC, a Note (i.e., a Clinical Note, also known as “Clinical Document”) is a document generated by a clinician as part of patient care and includes notes written at the initiative of “individual clinic and consulting clinicians.” In contrast, a Report is usually generated in response to an order, e.g., radiology, pathology, and cardiac catheterization reports. In general, we will not make two distinct LOINC codes for concepts that have all of the same attributes except that one is a Note and one is a Report. Requests for such pairs of codes (or a request for a note when a report term exists or vice versa) will be reviewed on a case by case basis.

Clinical documents meet five criteria, as defined in CDA 1.0: wholeness, stewardship, authentication, persistence, and human readability.

6.3.2 Type of Service

Describes the healthcare service or action provided to/for the patient (or other subject of the service) as described in the note. Examples include Referral, Consultation, Discharge summary, Communication, Disability examination, Procedure.

6.3.3 Setting

The healthcare environment or context in which the document was generated. Examples include Patient’s home, Emergency department, Hospital, Outpatient, Nursing facility.

Most clinical report names would include a setting (at least at the top level) to avoid confusion between important classes of reports. For example, The Admission H\&P is usually taken to be the Hospital Admission H\&P, but it could be confused with the nursing home H\&P if not distinguished by the setting. Setting is not a required component of the name.

6.3.4 Subject Matter Domain (SMD)

Characterizes the general focus or domain of knowledge represented within the content of the note. Typically values represent medical specialties but there is no requirement that the author have licensure or registration in that field. Examples include Audiology, Neurology, Cardiac Surgery, Nephrology.

6.3.5 Role

Characterizes the general function, responsibility, or capabilities of the author in relation to a document. The role category is a high-level classification that does not get as detailed as specialty or subspecialty so as to avoid potential overlap with the subject matter domain axis. Examples include Physician, Nurse, Social worker, Device.