Rekord LOINC: 77601-3
Tylko wersja angielska TRIAL
Szczegóły rekordu LOINC
Informacje podstawowe
| Kod LOINC: |
77601-3
FHIR
|
| Long Common Name: | Enhanced note |
| Short Name: | Enhanced note |
| Status: | TRIAL |
| Class Type: | 2 |
Fully Specified Name (FSN)
EN
Oryginalna wersja angielska
Enhanced note
:
Find
:
Pt
:
{Setting}
:
Doc
:
{Role}
Klasyfikacja
| Class: |
ENDOC.MISC
|
| Consumer Name: | - |
| Order/Observation: | Both |
| Panel Type: | - |
Informacje dodatkowe
| Units Required: | - |
| Example Units: | - |
| UCUM Units: | - |
| Version Last Changed: | 2.63 |
Definicja i opis
EN
An enhanced note is generated by a provider at the end of an office visit, consult, or home health encounter with a patient. Enhanced encounters may involve face-to-face time with the patient or may fall under the auspices of tele-medicine visits. An enhanced note includes all sections relevant to the specific visit, except for details concerning procedures, operations or imaging performed during the encounter. The document is intended to support the entire contents of the medical record related to a specific encounter with a patient for the administrative or clinical exchange with a third party. This term was created for, but not limited in use to, the Enhanced Encounter Document level template included in the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1.
Powiązane nazwy
DOC.MISC; Document; Encounter; Evaluation and management; Evaluation and management note; Finding; Findings; MISC; notes; Point in time; Random; Visit note