Version 2.78

Status Information

Status
TRIAL

Term Description

This document contains additional documentation captured by the provider related to care provided or planned for the patient that is not supported in any other section of the document. This term was created for, but not limited in use to, the Additional documentation section in the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Additional documentation
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
{Role}

Additional Names

Short Name
Additional documentation

Basic Attributes

Class
DOC.MISC
Type
Clinical
First Released
Version 2.52
Last Updated
Version 2.63
Change Reason
Previous Releases: Based on Clinical LOINC Committee decision during the September 2014 meeting, {Provider} was changed to {Author Type} to emphasize a greater breadth of potential document authors. At the September 2015 Clinical LOINC Committee meeting, the Committee decided to change {Author Type} to {Role} to align with the 'Role' axis name in the LOINC Document Ontology.;
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
81242-0 Enhanced discharge summary - recommended CDP Set 1 R1.0 sections
81615-7 Enhanced discharge summary - recommended CDP Set 1 R1.1 sections
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
81244-6 Enhanced procedure note - recommended CDP Set 1 R1.0 and R1.1 sections
81241-2 Enhanced surgical operation note - recommended CDP Set 1 R1.0 and R1.1sections
81245-3 Interval document - recommended CDP Set 1 R1.0 and R1.1 sections

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Ergänzende Dokumentation:Befund:Zeitpunkt:{Setting}:Dokument:{Funktion}
es-MX Spanish (Mexico) Documentación adicional:Tipo:Punto temporal:{Configuración}:Documento:{Role}
it-IT Italian (Italy) Ulteriore documentazione:Osservazione:Pt:{Setting}:Doc:{Role}
Synonyms: Documentazione miscellanea Miscellanea Osservazione Punto nel tempo (episodio) Ruolo non specificato
zh-CN Chinese (China) 附加文档记录:发现:时间点:{环境}:文档型:{角色}
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 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.其他;杂项类文档;其他文档 时刻;随机;随意;瞬间 未加明确说明的角色 杂项;杂项类;杂项试验 附加文档;附加文件;额外文档记录;其他文档记录 附加的 额外 额外的

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=77599-9