Surgical operation note preoperative diagnosis Narrative   10219-4

LOINC Code


LOINC code10219-4
nameSurgical operation note preoperative diagnosis Narrative
descriptionThe Surgical operation note pre-operative diagnosis records the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.
statusACTIVE

Fully-Specified Name

componentSurgical operation note preoperative Dx
propertyImp  =  Impression/interpretation of study
timePt  =  Point in time:  To identify measures at a point in time. This is a synonym for “spot” or “random” as applied to urine measurements.
system^Patient
scaleNar  =  Narrative:  Text narrative, such as the description of a microscopic part of a surgical papule test.
method

Additional Names

short nameOperative note pre-op Dx

Basic Attributes

classH&P.SURG PROC
type2  Clinical
order vs. observationObservation

Associated Observations

LOINC codes that represent optional associated observation(s) for a clinical observation or laboratory test. A LOINC term may represent a single associated observation or panel containing several associated observations.

Member of these Panels

81241-2Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72227-2Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59270-9Surgical operative note panel

History/Usage

first released
last updated2.63
last change typeMIN  - change to field other than name

Related Names

Diagnosis
Encounter
Evaluation and management
Evaluation and management note
H+P
H+P.SURGICAL PROCEDURES
Impression
Impression/interpretation of study
Impressions
Interp
Interpretation
Narrative
notes
Operative note
Operative note pre-op Dx
P prime
Point in time
Pre-Op
Random
Report
Surg
Visit note

Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © 1995-2024, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://loinc.org/license for the full LOINC copyright and license.

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