Submitted by sabhyankar on 2020-10-23
Clinical Notes
Composed of both structured (i.e. obtained via pick-list and/or check the box) and unstructured (free text) data. A clinical note may include the history, Review of Systems (ROS), physical data, assessment, diagnosis, plan of care and evaluation of plan, patient teaching and other relevant data points.
Data Element |
Applicable Standard(s) |
---|---|
Consultation Note |
|
Discharge Summary Note |
|
History & Physical |
|
Imaging Narrative |
|
Procedure Note |
|
Progress Note |
|
Data Element |
Applicable Standard(s) |
---|---|
Consultation Note |
|
Discharge Summary Note |
|
History & Physical |
|
Procedure Note |
|
Progress Note |
|
Data Element |
---|
Comment
Submitted by sabhyankar on 2020-10-23
Submitted by sabhyankar on 2020-10-23
Clinical notes explanatory text
The LOINC Document Ontology Subcommittee recommends adding the following explanatory text below the Clinical Notes header, following the existing explanatory text: “LOINC document codes represent expected collections of information regardless of format (e.g., structured versus unstructured, electronic format versus PDF document). For each note type, there is a generic LOINC concept as well as more specific concepts that vary by setting, specialty, etc. In most clinical situations, use of a more specific code is encouraged.”