Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections   81241-2

LOINC Code


LOINC code81241-2
nameEnhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
descriptionThis panel contains the recommended sections for an enhanced surgical operation note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).
statusACTIVE

Fully-Specified Name

componentEnhanced surgical operation note - recommended CDP Set 1 R1.0 & R1.1 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 nameEncd Surg Op Nte CDP1 R1.0+R1.1

Basic Attributes

classPANEL.DOC
type2  Clinical

Panel Components

77599-9Additional documentation
77598-1Externally defined clinical data elements Document
77597-3Orders placed Document
18776-5Plan of care note
59774-0Procedure anesthesia Narrative
55109-3Complications Document
46264-8History of medical device use
10216-0Surgical operation note fluids Narrative
10223-6Surgical operation note surgical procedure Narrative
48768-6Payment sources Document
59772-4Planned procedure Narrative
10218-6Surgical operation note postoperative diagnosis Narrative
10219-4Surgical operation note preoperative diagnosis Narrative
29554-3Procedure Narrative
59775-7Procedure disposition Narrative
59770-8Procedure estimated blood loss Narrative
59776-5Procedure findings Narrative
59771-6Procedure implants Narrative
59768-2Procedure indications [Interpretation] Narrative
59773-2Procedure specimens taken Narrative
11537-8Surgical drains 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 updated2.58
last change typeMIN  - change to field other than name

Related Names

Encd Surg Op Nte CDP1 R1.0+R1.1
Encounter
Evaluation and management
Evaluation and management note
i
notes
Operative note
Pan
Panel
PANEL.DOC
Panl
Pnl
Point in time
Random
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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