Version 2.78

Term Description

The Surgical operation note pre-operative diagnosis records the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Surgical operation note preoperative Dx
Property
Imp
Time
Pt
System
^Patient
Scale
Nar
Method

Additional Names

Short Name
Operative note pre-op Dx

Basic Attributes

Class
H&P.SURG PROC
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.63
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
72227-2 Surgical operation note - recommended C-CDA R1.1 and R2.0 and R2.1 sections
59270-9 Surgical operative note panel

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) anotación quirúrgica: diagnóstico preoperatorio:impresión/interpretación del estudio:punto en el tiempo:^paciente:Narrativo:
es-MX Spanish (Mexico) Nota de operación quirúrgica preoperatoria Dx:Interpretación:Punto temporal:^ Paciente:Narrativo:
fr-BE French (Belgium) Note opération chirurgicale. Diagnostic préopératoire:Impression/interprétation d'étude:Temps ponctuel:^Patient:Narratif:
it-IT Italian (Italy) Nota di operazione chirurgica, Dx preoperatoria:Imp:Pt:^Paziente:Nar:
Synonyms: Diagnosi preoperatoria in nota di intervento chiru Impressione/interpretazione di studio Nota di intervento chirurgico paziente Procedura chirurgica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) operatieverslag preoperatieve diagnose:interpretatie:moment:^patiënt:tekstueel:
ru-RU Russian (Russian Federation) Хирургическая операция запись предоперационный Dx:Впчт:ТчкВрм:^Пациент:Опис:
Synonyms: Впечатление/интерпретация исследования Описательный Послеоперационный эпикриз Точка во времени;Момент
zh-CN Chinese (China) 外科手术记录术前诊断:印象:时间点:^患者:叙述型:
Synonyms: Dx 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述，始终是对其他某种观察指标的解释或抽象（一系列检验项目结果、一幅图像或者整个某位病人），而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查.外科手术操作历史;历史纪录与体格检查.外科手术操作历史记录;历史纪录与体格检查.手术操作历史;历史纪录与体格检查.手术操作历史记录;历史纪录与体格检查.手术操作史;历史纪录与体格检查小节.外科手术操作历史;历史纪录与体格检查小节.外科手术操作历史记录;历史纪录与体格检查小节.手术操作历史;历史纪录与体格检查小节.手术操作历史记录;历史纪录与体格检查小节.手术操作史;外科手术操作历史;外科手术操作历史记录;手术操作历史;手术操作历史记录;手术操作史;病史与体格检查.外科手术操作历史;病史 历史纪录与体格检查小节 叙述;叙述性文字;报告;报告型;文字叙述;文本叙述型;文本描述;文本描述型 手术操作记录;外科手术操作记录;手术记录 手术操作记录术前诊断;外科手术操作记录术前诊断;手术记录术前诊断;外科手术记录手术前诊断;外科手术记录-术前诊断;外科手术（外科学手术、外科手术、手术、手术操作）记录术前（手术前、外科手术前、外科学手术前）诊断 时刻;随机;随意;瞬间 病史与体格检查 笔记;按语;注释;说明;票据;单据;证明书 诊断（Diagnosis，Dx）

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=10219-4