Rekord LOINC: 51855-5
Tylko wersja angielska ACTIVE
Szczegóły rekordu LOINC
Informacje podstawowe
| Kod LOINC: |
51855-5
FHIR
|
| Long Common Name: | Patient Note |
| Short Name: | Patient Note |
| Status: | ACTIVE |
| Class Type: | 2 |
Fully Specified Name (FSN)
EN
Oryginalna wersja angielska
Note
:
Find
:
Pt
:
{Setting}
:
Doc
:
Patient
Klasyfikacja
| Class: |
ENDOC.ONTOLOGY
|
| Consumer Name: | - |
| Order/Observation: | Both |
| Panel Type: | - |
Informacje dodatkowe
| Units Required: | N |
| Example Units: | - |
| UCUM Units: | - |
| Version Last Changed: | 2.50 |
Definicja i opis
EN
A patient authored note is generated by a patient, or a patient agent (proxy), acting in a non-clinical role to provide clinically relevant information. The information within the note is used to support planned or unplanned health care services. This document gives healthcare providers and others involved in a person's care information which the patient considers essential input during care delivery and coordination. This document enables patients and their agents to contribute to the continuity of care. The patient agent may not have a legally defined relationship with the patient (e.g. a close friend). Because a patient authored note is generated by a person acting as a non-clinician, this document may not be a complete medical summary and should be considered in context with other information routinely collected by clinicians during care delivery and coordination. This general class of patient authored notes includes information that is interoperable with data defined for clinician-generated documents. Other more specific classes of patient authored notes may include more tightly defined content. This document may be generated from a patient-, clinician-, or payer-controlled source system.
Powiązane nazwy
DOC.ONT; Document; Encounter; Evaluation and management; Evaluation and management note; Finding; Findings; notes; Point in time; Random; Visit note