Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections   81243-8

LOINC Code


LOINC code81243-8
nameEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
descriptionThis panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).
statusACTIVE

Fully-Specified Name

componentEnhanced encounter 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 Encounter Nte CDP1 R1.0+1.1

Basic Attributes

classPANEL.DOC
type2  Clinical

Panel Components

77599-9Additional documentation
77598-1Externally defined clinical data elements Document
47420-5Functional status assessment note
77597-3Orders placed Document
18776-5Plan of care note
29762-2Social history Narrative
77596-5Transportation summary Document
42348-3Advance directives
48765-2Allergies and adverse reactions Document
51847-2Evaluation + Plan note
51848-0Evaluation note
46239-0Chief complaint+Reason for visit Narrative
10154-3Chief complaint Narrative - Reported
46240-8History of Hospitalizations+Outpatient visits Narrative
10157-6History of family member diseases Narrative
10210-3Physical findings of General status Narrative
61146-7Goals Narrative
75310-3Health concerns Document
11383-7Patient problem outcome Narrative
11348-0History of Past illness Narrative
10164-2History of Present illness Narrative
11369-6History of Immunization Narrative
69730-0Instructions
62387-6Interventions Narrative
46264-8History of medical device use
10160-0History of Medication use Narrative
10190-7Mental status Narrative
61144-2Diet and nutrition Narrative
61149-1Objective Narrative
48768-6Payment sources Document
29545-1Physical findings Narrative
11450-4Problem list - Reported
47519-4History of Procedures Document
42349-1Reason for referral (narrative)
29299-5Reason for visit Narrative
30954-2Relevant diagnostic tests/laboratory data Narrative
10187-3Review of systems Narrative - Reported
61150-9Subjective 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 updated2.58
last change typeMIN  - change to field other than name

Related Names

Encd Encounter Nte CDP1 R1.0+1.1
Encounter
Evaluation and management
Evaluation and management note
i
notes
Pan
Panel
PANEL.DOC
Panl
Pnl
Point in time
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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