Enhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections:-:Pt:{Setting}:-:

Preferred Label : Enhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections:-:Pt:{Setting}:-:;

LOINC status : ACTIVE;

LOINC long common name : Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections;

LOINC short name : Encd Encounter Nte CDP1 R1.0 1.1;

LOINC description : This panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).;

Détails

Origin ID

81243-8;

UMLS CUI

C4266208;

Has component
- Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections [LOINC component]
- Note [LOINC component]
Has system
- {Setting} [LOINC System]
Has time aspect
- Point in time (spot) [LOINC time aspect]
Panel of LOINC codes
- Additional documentation:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Advance healthcare directives:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- 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]
- Evaluation note:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Evaluation+Plan note:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Externally defined clinical data elements:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Functional status assessment note:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Goals:Find:Pt:^Patient:Nar: [LOINC code]
- Health concerns:Find:Pt:^Patient:Doc: [LOINC code]
- History of family member diseases:Hx:Pt:^Family member:Nar: [LOINC code]
- History of medical device use:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- History of procedures:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Hospitalizations+Outpatient visits:Hx:Pt:^Patient:Nar: [LOINC code]
- Immunization:Hx:Pt:^Patient:Nar: [LOINC code]
- Instructions:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Interventions:Find:Pt:^Patient:Nar: [LOINC code]
- Medication use:Hx:Pt:^Patient:Nar: [LOINC code]
- Mental status:Find:Pt:^Patient:Nar:Observed [LOINC code]
- Objective:Find:Pt:^Patient:Nar: [LOINC code]
- Orders placed:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Past illness:Hx:Pt:^Patient:Nar: [LOINC code]
- Patient problem outcome:Find:Pt:^Patient:Nar: [LOINC code]
- Payment sources:Find:Pt:^Patient:Doc: [LOINC code]
- Physical findings:Find:Pt:General status:Nar:Observed [LOINC code]
- Physical findings:Find:Pt:^Patient:Nar:Observed [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 referral:Find:Pt:^Patient:Nar: [LOINC code]
- Reason for visit:Find:Pt:^Patient:Nar: [LOINC code]
- Relevant diagnostic tests &or laboratory data:Find:Pt:^Patient:Nar: [LOINC code]
- Review of systems:Find:Pt:^Patient:Nar:Reported [LOINC code]
- Social history:Find:Pt:^Patient:Nar: [LOINC code]
- Subjective:Find:Pt:^Patient:Nar: [LOINC code]
- Transportation summary:Find:Pt:{Setting}:Doc:{Role} [LOINC code]
- Vital signs:Find:Pt:^Patient:Nar:Observed [LOINC code]
Semantic type(s)
- Clinical Attribute [UMLS semantic type]

Position du mot-clé dans l'(les) arborescence(s) :

Vous pouvez consulter :

recommendations
documents concerning education
documents for patients