Discharge summary - recommended C-CDA R2.0 sections:-:Pt:{Setting}:-:

Preferred Label : Discharge summary - recommended C-CDA R2.0 sections:-:Pt:{Setting}:-:;

LOINC status : ACTIVE;

LOINC long common name : Discharge summary - recommended C-CDA R2.0 sections;

LOINC short name : Discharge Sum C-CDA R2.0 Sections;

LOINC description : This panel contains the recommended sections for discharge summary notes based on the HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 2.0.;

Details

Origin ID

81219-8;

UMLS CUI

C4255377;

Has component
- Discharge [LOINC component]
- Discharge summary - recommended C-CDA R2.0 sections [LOINC component]
- Summary [LOINC component]
Has system
- {Setting} [LOINC System]
Has time aspect
- Point in time (spot) [LOINC time aspect]
Panel of LOINC codes
- Allergies &or adverse reactions:Find:Pt:^Patient:Doc: [LOINC code]
- Chief complaint+Reason for visit:Find:Pt:^Patient:Nar: [LOINC code]
- Chief complaint:Find:Pt:^Patient:Nar:Reported [LOINC code]
- Diet and nutrition:Find:Pt:^Patient:Nar: [LOINC code]
- Discharge diet:Find:Pt:^Patient:Nar: [LOINC code]
- Discharge instructions:Find:Pt:Hospital:Doc:{Role} [LOINC code]
- Functional status assessment note:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- History of family member diseases:Hx:Pt:^Family member:Nar: [LOINC code]
- History of procedures:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Hospital admission Dx:Imp:Pt:^Patient:Nar:Reported [LOINC code]
- Hospital consultations:Find:Pt:^Patient:Doc: [LOINC code]
- Hospital course:Find:Pt:^Patient:Nar: [LOINC code]
- Hospital discharge Dx:Imp:Pt:^Patient:Nar: [LOINC code]
- Hospital discharge medications:Find:Pt:^Patient:Nar: [LOINC code]
- Hospital discharge physical findings:Find:Pt:^Patient:Nar: [LOINC code]
- Hospital discharge studies summary:Find:Pt:^Patient:Nar: [LOINC code]
- Immunization:Hx:Pt:^Patient:Nar: [LOINC code]
- Medications on admission:Find:Pt:^Patient:Nar: [LOINC code]
- Past illness:Hx:Pt:^Patient:Nar: [LOINC code]
- Plan of care note:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Present illness:Hx:Pt:^Patient:Nar: [LOINC code]
- Problem list:Find:Pt:^Patient:Nom:Reported [LOINC code]
- Reason for visit:Find:Pt:^Patient:Nar: [LOINC code]
- Review of systems:Find:Pt:^Patient:Nar:Reported [LOINC code]
- Social history:Find:Pt:^Patient:Nar: [LOINC code]
- Vital signs:Find:Pt:^Patient:Nar:Observed [LOINC code]
Semantic type(s)
- Clinical Attribute [UMLS semantic type]

Keyword's position in hierarchy(ies) :

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