77599-9 Additional documentation

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

Observation Required in Panel

Required

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

Language Variants Get Info

Related Names

• Add
• DOC.MISC
• Document
• Finding
• Findings
• MISC
• Point in time
• Random

77598-1 Externally defined clinical data elements Document

Term Description

Externally defined clinical data elements section contains data that may be created through the interaction of the provider with templates (internal to the EHR or externally defined) that store XML tagged name-value pairs or more complex XML tagged information/content models and a reference to the externally defined information/content model, value set or clinical vocabulary. The referenced content model, value set or clinical vocabulary shall be pointed to by a URI in the Externally Defined CDA organizer and the specific XML tagged data shall be included in the Externally Defined CDE template. This term was created for, but not limited in use to, the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Externally defined clinical data elements

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Externally defined CDEs Doc

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

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Externally defined CDEs
• Finding
• Findings
• MISC
• Point in time
• Random

77597-3 Orders placed Document

Term Description

Orders placed section contains active and completed (not planned) orders for observations, interventions, encounters, services, and procedures for the patient. Order information is used to validate that clinical activities performed by other providers and suppliers authorized by the responsible provider. The details of orders are provided but not the acts involved in the processing and fulfillment of the order. In general, planned order activity is included under the plan of treatment section (also known as "plan of care") [LOINC: 18776-5]. This term was created for, but not limited in use to, the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Orders placed

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Orders placed Doc

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

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• MISC
• Point in time
• Random

18776-5 Plan of care note

Term Description

Plan of care notes (previously defined as "Plan of treatment") contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. The plan includes prospective, unfulfilled, or incomplete orders and requests only. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Plan of care note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Plan of care note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 1.0l

Last Updated

Version 2.67

Change Reason

Previous Releases: Based on Clinical LOINC Committee review (2/2016), it was decided that there is little, if any, distinction between plan of treatment and plan of care notes. This term was meant to represent a general plan of care/treatment note. In order to align with the LOINC Document Ontology model, the Component was changed from "Plan of treatment" to "Plan of Care note", System changed from "Treatment plan" to {Setting}, Scale changed from "Nar" to "Doc" and Method changed from null to {Role}.;

Order vs. Observation

Both

HL7^® Attachment Structure

IG exists

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Care plan
• DOC.ONT
• Document
• Encounter
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• notes
• Point in time
• Random
• Treatment plan
• Visit note

29762-2 Social history Narrative

Term Description

The Social history section contains data defining the patient's occupational, personal (e.g. lifestyle), social, and environmental history and health risk factors, as well as administrative data such as marital status, race, ethnicity and religious affiliation.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Social history

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Social Hx

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Hx
• Narrative
• P prime
• Point in time
• Random
• Report
• Social Hx

48765-2 Allergies

Term Description

Contains a list and description of any allergies or adverse reactions pertinent to current or past medical history. At a minimum this section should contain currently active and any relevant historical allergies and adverse reactions.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Allergies &or adverse reactions

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Additional Names

Short Name

Allergies &or adverse reactions Doc

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73

Change Reason

Previous Releases: Edited Component part from "Allergies, adverse reactions, alerts" to "Allergies &or adverse reactions." We removed the word "alerts" because it was potentially confusing by implying that it may contain other kinds of warnings (as a arbitrary example: public health disease outbreak notifications) when in fact it was always intended to be the typical "allergies" section.;

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• MISC
• Point in time
• Random

59774-0 Procedure anesthesia Narrative

Term Description

The Anesthesia section briefly records the type of anesthesia (e.g., general, conscious, or local) and may state the actual agent(s) used.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Procedure anesthesia

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Anesthesia

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

51847-2 Evaluation + Plan note

Term Description

The Assessment and Plan note (also called impression or diagnoses) represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The assessment formulates a specific plan or set of recommendations. The assessment may be a list of specific disease entities or a narrative block. The Plan section contains data that defines pending orders, interventions, encounters, services, and procedures for the patient. It is limited to prospective, unfulfilled, or incomplete orders and requests only. All active, incomplete, or pending orders, appointments, referrals, procedures, services, or any other pending event of clinical significance to the current care of the patient should be listed unless constrained due to privacy issues. The plan may also contain information about ongoing care of the patient and information regarding goals and clinical reminders. Clinical reminders are placed here to provide prompts for disease prevention and management, patient safety, and health-care quality improvements, including widely accepted performance measures. The plan may also indicate that patient education was given or will be provided.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation+Plan note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Eval+Plan note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.63

Change Reason

Previous Releases: Changed 'Assesment' to 'Evaluation' to harmonize existing terms with similar meaning. The term 'Evaluation' will be used in the LOINC Document Ontoloy based on Clinical LOINC Committee decision (Sept 2014).; 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

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Assessment
• Assessment+Plan note
• DOC.ONT
• Document
• Encounter
• Eval
• Eval+Plan note
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H&P
• History and physical
• notes
• Point in time
• Random
• Visit note

51848-0 Evaluation note

Observation Required in Panel

Required

Fully-Specified Name

Component

Evaluation note

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Eval note

Basic Attributes

Class

DOC.ONTOLOGY

Type

Clinical

First Released

Version 2.24

Last Updated

Version 2.73

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

Common Test Rank Get Info

6628

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Assessment
• DOC.ONT
• Document
• Encounter
• Eval
• Eval note
• Evaluation and management
• Evaluation and management note
• Finding
• Findings
• H&P
• History and physical
• notes
• Point in time
• Random
• Visit note

46239-0 Chief complaint+Reason for visit Narrative

Term Description

This term is used to record the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Chief complaint+Reason for visit

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Chief complaint+Reason for visit

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.63

Order vs. Observation

Observation

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

10154-3 Chief complaint Narrative - Reported

Term Description

Chief complaint records the patient's primary complaint (the patient's own description).
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Chief complaint

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Additional Names

Short Name

Chief complaint Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Narrative
• P prime
• Point in time
• Random
• Report

55109-3 Complications Document

Term Description

Information on additional medical problems that develop following a procedure, diagnostic test or study, treatment, or illness.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Complications

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Additional Names

Short Name

Complications Doc

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.27

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• MISC
• Point in time
• Random

Related Codes

10157-6 History of family member diseases Narrative

Term Description

History of family member diseases is a report of health information, including medical, genetic, environmental, and lifestyle factors, pertaining to the patient and his or her genetic relatives (living or deceased). The family history information is used to determine possible or relevant health risk factors that may have a potential impact on the patient's healthcare risk profile.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

History of family member diseases

Property

Hx

Time

Pt

System

^Family member

Scale

Nar

Method

Additional Names

Short Name

Family member diseases Hx

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.73

Change Reason

Previous Releases: Changed Property from "Find" to "Hx", removed Method of "Reported" and corrected System from Family to ^Family member to align with existing family history terms and to represent family member as a Super System per 8/2015 Clinical LOINC Committee decision;

Common Test Rank Get Info

9825

Member of these Panels

Language Variants Get Info

Related Names

• Fam Mem
• Family member diseases Hx
• H/O
• H+P
• H+P.HX
• History
• Hx
• Narrative
• P prime
• Point in time
• Random
• Report

11348-0 History of Past illness Narrative

Term Description

History of past illness describes the history related to their current complaints, problems, or diagnoses.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Past illness

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Past illness

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.63

Change Reason

Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Last
• Narrative
• P prime
• Point in time
• Random
• Report

10164-2 History of Present illness Narrative

Term Description

History of present illness describes the history related to the reason for a given procedure. It contains the historical details leading up to and pertaining to the patient's current complaint or reason for seeking medical care. Because history of present illness can include past surgical history and other procedures, the Procedure History section may be included under the History of Present Illness section or it may stand alone as its own section.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Present illness

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Pres illness

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Change Reason

Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Narrative
• P prime
• Point in time
• Pres illness
• Random
• Report

11329-0 History general Narrative - Reported

Term Description

History general describes all aspects of medical history of the patient even if not pertinent to the current procedure, and may include chief complaint, past medical history, social history, family history, surgical or procedure history, medication history, and other history information. The history may be limited to information pertinent to the current procedure or may be more comprehensive. It may also be reported as a collection of random clinical statements or it may be reported categorically. Categorical report formats may be divided into multiple subsections, including Past Medical History and Social History.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

History general

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Reported

Additional Names

Short Name

Hx general Reported

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0j-a

Last Updated

Version 2.73

Common Test Rank Get Info

3158

Member of these Panels

Language Variants Get Info

Related Names

• Finding
• Findings
• H+P
• H+P.HX
• Hx
• Hx general
• Narrative
• P prime
• Point in time
• Random
• Report

Related Codes

46264-8 History of medical device use

Term Description

History of medical device (medical equipment) use defines a patient's implanted and external medical devices and equipment that their health status depends on, as well as any pertinent equipment or device history. This term is also used to itemize any pertinent current or historical durable medical equipment (DME) used to help maintain the patient's health status. All pertinent equipment relevant to the diagnosis, care, and treatment of a patient should be included.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

History of medical device use

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Hx medical device use

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.19

Last Updated

Version 2.67

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

Observation

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Finding
• Findings
• H/O
• Hx
• Medical device use Hx
• MISC
• Point in time
• Random

29549-3 Medication administered Narrative

Term Description

Medications administered defines medications and fluids administered during the procedure, excluding anesthetic medications. Medications administered for anesthesia are typically documented in the section on Anesthesia.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Medication administered

Property

Type

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Medication administered

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.40

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.PX
• Medication.administered
• Narrative
• P prime
• Point in time
• Random
• Report
• Typ

10160-0 History of Medication use Narrative

Term Description

History of medication use defines a patient's current medications and history of pertinent medications. This term may also include a patient's prescription and dispense history.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Medication use

Property

Hx

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Hx of Medication use

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 1.0i

Last Updated

Version 2.63

Change Reason

Previous Releases: Removed "History of" from Component, changed Property from "Find" to "Hx", and removed "Reported" Method per 8/2015 Clinical LOINC Committee decision;

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.HX
• History
• Narrative
• P prime
• Point in time
• Random
• Report

48768-6 Payment sources Document

Term Description

Contains data on the patient's payers, whether a 'third party' insurance, self-pay, other payer or guarantor, or some combination of payers, and is used to define which entity is the responsible fiduciary for the financial aspects of a patient's care.

Each unique instance of a payer and all the pertinent data needed to contact, bill to, and collect from that payer should be included. Authorization information that can be used to define pertinent referral, authorization tracking number, procedure, therapy, intervention, device, or similar authorizations for the patient or provider, or both should be included. At a minimum, the patient's pertinent current payment sources should be listed.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Payment sources

Property

Find

Time

Pt

System

^Patient

Scale

Doc

Method

Additional Names

Short Name

Payment sources Doc

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.21

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Document
• Financing and insurance
• Finding
• Findings
• MISC
• Payers
• Point in time
• Random

29545-1 Physical findings Narrative

Observation Required in Panel

Required

Fully-Specified Name

Component

Physical findings

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Observed

Additional Names

Short Name

Phys find

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.63

Member of these Panels

Language Variants Get Info

Related Names

• Exam
• Examination
• Finding
• Findings
• H+P
• H+P.PX
• Narrative
• P prime
• Phys find
• Point in time
• Random
• Report

59772-4 Planned procedure Narrative

Term Description

The Planned Procedure section records the procedure(s) that the clinician thought would be needed based on the pre-procedure assessment.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Planned procedure

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Planned procedure

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

59769-0 Postprocedure diagnosis Narrative

Term Description

The Postprocedure Diagnosis section records the diagnosis or diagnoses discovered or confirmed during the procedure.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Postprocedure diagnosis

Property

Imp

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Postprocedure Dx

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Dx
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• MISC
• Narrative
• Point in time
• Postprocedure Dx
• Random
• Report

29554-3 Procedure Narrative

Term Description

Procedure records the descriptions of the procedure with an extensive narrative and may include procedure site preparation, pertinent details related to measurements and markings, procedure times, instrumentation, and vital signs and other monitoring data.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Procedure

Property

Type

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Procedure

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.40

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.PX
• Narrative
• P prime
• Point in time
• Random
• Report
• Typ

59775-7 Procedure disposition Narrative

Term Description

The Procedure disposition section records the status and condition of the patient at the completion of the procedure or surgery. It often also states where the patent was transferred to for the next level of care.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Procedure disposition

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Disposition

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

59770-8 Procedure estimated blood loss Narrative

Term Description

Procedure estimated blood loss is the approximate amount of blood that the patient lost during the procedure or surgery. It may be an accurate quantitative amount, e.g., 250 milliliters, or it may be descriptive, e.g., "minimal" or "none".
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Procedure estimated blood loss

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Estimated blood loss

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Common Test Rank Get Info

6933

Member of these Panels

Language Variants Get Info

Related Names

• Bld loss
• Blood output
• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

59776-5 Procedure findings Narrative

Term Description

The Procedure findings section records clinically significant observations confirmed or discovered during a procedure, treatment or service.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Procedure findings

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Findings

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

59771-6 Procedure implants Narrative

Term Description

The Procedure implants section records any materials placed during a procedure including stents, tubes, and drains.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Procedure implants

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Implants

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

59768-2 Procedure indications [Interpretation] Narrative

Term Description

The Procedure indications section records details about the reason for the procedure, treatment or service.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Procedure indications

Property

Imp

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Procedure indications Imp

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• MISC
• Narrative
• Point in time
• Random
• Report

59773-2 Procedure specimens taken Narrative

Term Description

The Procedure specimens taken section records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis. The narrative may include a description of the specimens.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

Procedure specimens taken

Property

Find

Time

Pt

System

^Patient

Scale

Nar

Method

Additional Names

Short Name

Specimens taken

Basic Attributes

Class

DOC.MISC

Type

Clinical

First Released

Version 2.32

Last Updated

Version 2.73

Order vs. Observation

Both

Member of these Panels

Language Variants Get Info

Related Names

• DOC.MISC
• Finding
• Findings
• MISC
• Narrative
• Point in time
• Random
• Report

47519-4 History of Procedures Document

Term Description

This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically and at the time the document is generated.
Source: Regenstrief LOINC

Observation Required in Panel

Required

Fully-Specified Name

Component

History of procedures

Property

Find

Time

Pt

System

{Setting}

Scale

Doc

Method

{Role}

Additional Names

Short Name

Procedures Hx Doc

Basic Attributes

Class

H&P.HX

Type

Clinical

First Released

Version 2.19

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.;

Member of these Panels