Version 2.78

Term Description

A patient authored note is generated by a patient, or a patient agent (proxy), acting in a non-clinical role to provide clinically relevant information. The information within the note is used to support planned or unplanned health care services.

This document gives healthcare providers and others involved in a person's care information which the patient considers essential input during care delivery and coordination. This document enables patients and their agents to contribute to the continuity of care. The patient agent may not have a legally defined relationship with the patient (e.g. a close friend).

Because a patient authored note is generated by a person acting as a non-clinician, this document may not be a complete medical summary and should be considered in context with other information routinely collected by clinicians during care delivery and coordination.

This general class of patient authored notes includes information that is interoperable with data defined for clinician-generated documents. Other more specific classes of patient authored notes may include more tightly defined content.

This document may be generated from a patient-, clinician-, or payer-controlled source system.
Source: Regenstrief LOINC

Part Description

LP66710-2   Patient
Clinical information generated by a patient, or a patient agent (proxy), acting in a non-clinical role to provide clinically relevant information. The patient agent may not have a legally defined relationship with the patient (e.g. a close friend). Source: Regenstrief LOINC

Fully-Specified Name

Component
Note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Patient

Additional Names

Short Name
Patient Note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.50
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name Answer List Answer List Type Answers
100062-9 Standard Dermatology Outcome Measures panel LL361-7 Normative 2

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38748-6 Note|ANYRole|ANYSetting
LG39005-0 Patient|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Patientendokument
de-DE German (Germany) Notiz:Befund:Zeitpunkt:{Setting}:Dokument:Patient
es-MX Spanish (Mexico) Nota:Tipo:Punto temporal:{Configuración}:Documento:Patient
it-IT Italian (Italy) Nota:Osservazione:Pt:{Setting}:Doc:Paziente
Synonyms: Documentazione dell''ontologia Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verslag:bevinding:moment:{instelling}:document:patiënt
zh-CN Chinese (China) 记录:发现:时间点:{环境}:文档型:患者
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 医疗服务对象;客户;病人;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 笔记;按语;注释;说明;票据;单据;证明书

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=51855-5