Version 2.82

Part Description

LP74249-1   Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure. Source: HL7

LOINC Names Get Info

Fully-Specified Name
Procedure note:Find:Pt:{Setting}:Doc:{Role}
Long Common Name
Procedure note
Short Name
Procedure note

Part Model Get Info

  • Component
    Procedure note
    LP74249-1
    • Analyte
      Procedure note
      LP74249-1
      • Component Numerator
        Procedure note
        LP74249-1
        • Component Numerator Core
          Procedure note
          LP74249-1
        • 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
    • Time Core
      Pt
      LP6960-1
    • Time Modifier
      NULL
       
  • System
    {Setting}
    LP32887-9
    • System Core
      {Setting}
      LP32887-9
    • Super System
      NULL
       
  • Scale
    Doc
    LP32888-7
  • Method
    {Role}
    LP187178-1

Associated Observations

81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections

This panel contains the recommended sections for procedure notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
81217-2 Procedure note - recommended C-CDA R2.0 and R2.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent55109-3 Complications Document R
Indent29554-3 Procedure description R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent48765-2 Allergies O
Indent59774-0 Procedure anesthesia Narrative O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10154-3 Chief complaint Narrative - Reported O
Indent10157-6 Family history O
Indent11348-0 History of Past illness note O
Indent10164-2 History of Present illness Narrative O
Indent11348-0 Past medical history O
Indent29549-3 Medication administered Narrative O
Indent10160-0 Medications O
Indent29545-1 Physical examination O
Indent59772-4 Planned procedure Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59770-8 Procedure estimated blood loss Narrative O
Indent59776-5 Procedure findings Narrative O
Indent59771-6 Procedure implants Narrative O
Indent59773-2 Procedure specimens taken Narrative O
Indent47519-4 History of Procedures Document O
Indent29299-5 Reason for visit O
Indent10187-3 Review of systems Narrative - Reported O
Indent29762-2 Social history note O

59843-3 Procedure note - recommended C-CDA R1.1 sections

This panel contains the recommended sections for procedure notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.

LOINC Name R/O/C Cardinality Example UCUM Units
59843-3 Procedure note - recommended C-CDA R1.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent55109-3 Complications Document R
Indent59769-0 Postprocedure diagnosis Narrative R
Indent29554-3 Procedure description R
Indent59768-2 Procedure indications [Interpretation] Narrative R
Indent59770-8 Procedure estimated blood loss Narrative O
Indent59771-6 Procedure implants Narrative O
Indent59772-4 Planned procedure Narrative O
Indent59773-2 Procedure specimens taken Narrative O
Indent59774-0 Procedure anesthesia Narrative O
Indent59775-7 Procedure disposition Narrative O
Indent59776-5 Procedure findings Narrative O
Indent29545-1 Physical examination R
Indent29299-5 Reason for visit C
Indent48765-2 Allergies O
Indent10154-3 Chief complaint Narrative - Reported O
Indent46239-0 Chief complaint+Reason for visit Narrative O
Indent10157-6 Family history O
Indent10210-3 General status O
Indent11348-0 Past medical history O
Indent10160-0 Medications O
Indent29549-3 Medication administered Narrative O
Indent47519-4 History of Procedures Document O
Indent29762-2 Social history note O
Indent10187-3 Review of systems Narrative - Reported O

81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections

This panel contains the recommended sections for an enhanced procedure 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
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
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
Indent29762-2 Social history note R
Indent48765-2 Allergies R
Indent59774-0 Procedure anesthesia Narrative R
Indent51847-2 Evaluation + Plan note R
Indent51848-0 Evaluation note R
Indent46239-0 Chief complaint+Reason for visit Narrative R
Indent10154-3 Chief complaint Narrative - Reported R
Indent55109-3 Complications Document R
Indent10157-6 History of family member diseases note R
Indent11348-0 History of Past illness note R
Indent10164-2 History of Present illness Narrative R
Indent11329-0 History general Narrative - Reported R
Indent46264-8 History of medical device use R
Indent29549-3 Medication administered Narrative R
Indent10160-0 History of Medication use Narrative R
Indent48768-6 Payment sources Document R
Indent29545-1 Physical findings note R
Indent59772-4 Planned procedure Narrative R
Indent59769-0 Postprocedure 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
Indent47519-4 History of Procedures Document R
Indent29299-5 Reason for visit Narrative R
Indent10187-3 Review of systems Narrative - Reported R

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.00
Last Updated
Version 2.58 (MIN)
Change Reason
Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Panels

LOINC Long Common Name
26443-2 Clinical reports.non lab claims attachment
93340-8 PhenX - complete blood count protocol 220501

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38811-2 Procedure note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σημείωμα διαδικασίας:Εύρεση:Pt:{Ρυθμίσεις}:Doc:{Ρόλος}
Synonyms: {Ρόλος} {Ρυθμίσεις} Doc DOC.ONTOLOGY Pt Διαδικασία Εύρεση Σημείωμα διαδικασίας Σημείωση
es-ES Spanish (Spain) Nota de procedimiento:Hallazgo:Punto temporal:(Localización):Doc:Rol no especificado
es-AR Spanish (Argentina) nota de procedimiento:hallazgo:punto en el tiempo:{contexto}:Documento:{proveedor}
es-MX Spanish (Mexico) Nota de procedimiento:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Procedura, nota:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione dell''ontologia Nota di procedura Osservazione Punto nel tempo (episodio) Ruolo non specificato
nl-NL Dutch (Netherlands) verslag ingreep:bevinding:moment:{instelling}:document:{rol}
Synonyms: verslag procedure
zh-CN Chinese (China) 操作记录:发现:时间点:{环境}:文档型:{角色}
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 操作;程序;手续;步骤;规程;程序流程 操作项目记录 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 未加明确说明的角色 笔记;按语;注释;说明;票据;单据;证明书

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=28570-0