6.5 LOINC’s rules for creating clinical notes from multiple attributes

LOINC is working on a revised document model to represent documents. Until then, the following describes the current state of modeling using LOINC’s six-axis model.

Names for required clinical notes would be constructed by picking entries from the Kind of Document axis and at least one of the other four axes (see exceptions in Section 7.4.1). The LOINC committee will create LOINC codes for all required combinations (not all possible combinations).

The original Document Ontology terms were created only for the document type of “note” and with the general naming pattern:

<Subject Matter Domain> : <Training / Professional Level>: <Setting>: <Type> : Note

As we have revised and refined the elemental axes in the Document Ontology, simple names would be constructed and ordered as follows:

Component: <Type of Service> <Kind of Document>
Property: Find
Time: Pt
System: <Setting>
Scale: Doc
Method: <SMD>.<Role>
Class: DOC.ONTOLOGY

In general, combinations from within an axis are allowed in a term name where they make sense (typically, SMD and Service), but are disallowed where they do not (typically, Role and Setting). Combinations will be represented with a plus (+), so as to distinguish from elements containing “and” or “&”. Where a particular element is not defined for a given term and leaves a LOINC axis blank, the LOINC name will include the {} naming convention. For example, if a Setting is not designated, the System will be {Setting}. Where neither the SMD nor Role is specified, {Role} is used in the Method (as of LOINC version 2.54).

LOINC codes for clinical notes designed according to this model and are assigned a Class of DOC.ONTOLOGY. The Class name was changed in LOINC version 2.50 from DOC.CLINRPT to DOC.ONTOLOGY, a more representative name for all types of documents (not just clinical reports) included in the LOINC Document Ontology.

Example LOINC codes in the Document Ontology include:

For every clinical note term we create with a designated Setting, SMD, and/or Role, we will also create a general “roll-up” term where the Setting, SMD and Role are not specified, i.e. they are defined as {Setting} and {Role}. The LOINC Committee has agreed not to create a general document code in some cases, including:

1. The Component contains only one axis value, either a Type of Service or Kind of Document. Such a generic code (absent the other attributes) would violate the current policy to include the Kind of Document plus at least one other axis value.
2. The general type of clinical document is not likely to ever exist.

Example LOINC codes that do not have a general clinical note term include:

6.5.1 Exceptions to rules for creating clinical notes

As noted above, the current policy for creating clinical notes is to include the Kind of Document plus at least one other axis value. The LOINC Committee has agreed to make exceptions to the Document Ontology rules for cases where only Kind of Document is commonly designated (e.g. Driver license).

Example LOINC codes that are approved exceptions containing only a Kind of Document:

The LOINC Committee also recognizes the need for terms with only a general Kind of Document (e.g. Letter, Note, Report) designated. We have agreed to create such terms, however, they will have a status of “discouraged” to caution users. If these general terms are used, we strongly recommend that they are used in a post-coordinated manner in conjunction with one of the LOINC terms included in the LOINC Document Ontology associated observations panel (LOINC: 80582-0) to carry the relevant attribute specifications.