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

LOINC Code


LOINC code81217-2
nameProcedure note - recommended C-CDA R2.0 and R2.1 sections
descriptionThis 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.
statusACTIVE

Fully-Specified Name

componentProcedure note - recommended C-CDA R2.0 & R2.1 sections
property-
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{Setting}
scale-
method

Additional Names

short nameProced Nte C-CDA R2.0+2.1 Sections

Basic Attributes

classPANEL.DOC
type2  Clinical

Panel Components

51847-2Evaluation + Plan note
51848-0Evaluation note
18776-5Plan of care note
55109-3Complications Document
29554-3Procedure Narrative
59769-0Postprocedure diagnosis Narrative
59768-2Procedure indications [Interpretation] Narrative
48765-2Allergies and adverse reactions Document
59774-0Procedure anesthesia Narrative
46239-0Chief complaint+Reason for visit Narrative
10154-3Chief complaint Narrative - Reported
10157-6History of family member diseases Narrative
11348-0History of Past illness Narrative
10164-2History of Present illness Narrative
11348-0History of Past illness Narrative
29549-3Medication administered Narrative
10160-0History of Medication use Narrative
29545-1Physical findings Narrative
59772-4Planned procedure Narrative
59775-7Procedure disposition Narrative
59770-8Procedure estimated blood loss Narrative
59776-5Procedure findings Narrative
59771-6Procedure implants Narrative
59773-2Procedure specimens taken Narrative
47519-4History of Procedures Document
29299-5Reason for visit Narrative
10187-3Review of systems Narrative - Reported
29762-2Social history Narrative

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.

History/Usage

first released
last updated2.56
last change typeADD  - added

Related Names

Congenital dyserythropoietic anaemia
Encounter
Evaluation and management
Evaluation and management note
notes
Pan
Panel
PANEL.DOC
Panl
Pnl
Point in time
Proced Nte C-CDA R2.0+2.1 Sections
Random
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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