Discharge summary - recommended C-CDA R2.1 sections   81218-0

LOINC Code


LOINC code81218-0
nameDischarge summary - recommended C-CDA R2.1 sections
descriptionThis panel contains the recommended sections for discharge summary notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.1.
statusACTIVE

Fully-Specified Name

componentDischarge summary - recommended C-CDA 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 nameDischarge Sum C-CDA R2.1 Sections

Basic Attributes

classPANEL.DOC
type2  Clinical

Panel Components

48765-2Allergies and adverse reactions Document
8648-8Hospital course Narrative
78375-3Discharge diagnosis Narrative
75311-1Discharge medications Narrative
18776-5Plan of care note
42347-5Admission diagnosis (narrative)
42346-7Medications on admission (narrative)
46239-0Chief complaint+Reason for visit Narrative
10154-3Chief complaint Narrative - Reported
42344-2Discharge diet (narrative)
10157-6History of family member diseases Narrative
47420-5Functional status assessment note
11348-0History of Past illness Narrative
10164-2History of Present illness Narrative
18841-7Hospital consultations Document
8653-8Hospital Discharge instructions
10184-0Hospital discharge physical findings Narrative
11493-4Hospital discharge studies summary Narrative
11369-6History of Immunization Narrative
61144-2Diet and nutrition Narrative
11450-4Problem list - Reported
47519-4History of Procedures Document
29299-5Reason for visit Narrative
10187-3Review of systems Narrative - Reported
29762-2Social history Narrative
8716-3Vital signs

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
Disch
Discharge Sum C-CDA R2.1 Sections
Pan
Panel
PANEL.DOC
Panl
Pnl
Point in time
Random

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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