Pt = 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
{Setting}
scale
Doc = Document: A document that could be in many formats (XML, narrative, etc.)
method
Psychiatry
Additional Names
short name
Psychiatric Note
Basic Attributes
class
DOC.ONTOLOGY
type
2 Clinical
order vs. observation
Both
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.
Component was changed from 'Visit note' to 'Note', systerm was changed from ^Patient to {setting} and class was changed from ATTACH.CLINRPT to DOC.CLINRPT based on Clinical LOINC Committee approval at 8/16/2011 meeting. The Committee agreed that 'Occupational therapy visit note', for example, is essentially the same as a 'Occupational therapy note'. Other parts of term were changed to correspond with current document ontology.
Related Names
DOC.ONT Document Encounter Evaluation and management Evaluation and management note Finding Findings Mental health
MentalHealth notes Point in time Psych Psychiatric Psychiatry Random Visit note
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