92915-8  Immunology Consult noteImmunology Consult noteConsultation note: Find: Pt: {Setting}: Doc: Immunology  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Consultation note  Find  Pt  {Setting}  Doc  Immunology
  Long Common Name:  Immunology Consult note
  Short Name:  Immunology Consult note

PART DEFINITION/DESCRIPTION(S)
  Part: Consultation note
  Consultation note is generated by a physician or nonphysician practitioner's (NPP) upon request for an opinion or advice from another physician or NPP. Consultations may involve face-to-face time with the patient, telemedicine visits, or a second opinion on a diagnosis that does not involve interaction with a patient. A consultation note is often provided to the referring physician or NPP and may include the reason for the referral, history of present illness, physical examination, and decision-making component (Assessment and Plan).
 
 

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 2.66
  Last Updated in Version: 2.66
  Order vs. Obs.: Both
  HL7 Attachment Structure: IG exists
  Status: Active

ASSOCIATED OBSERVATIONS

Definition/Description: This panel contains the recommended sections for consultation notes based on HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81222-2   Consultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 and R2.1 sectionsConsultation note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:    
       51847-2   Assessment+Plan R    
       51848-0   Assessment R    
       18776-5   Plan of care R    
       11348-0   Past medical history R    
       29545-1   Physical examination R    
       29299-5   Reason for visit R    
       42348-3   Advance directivesAdvance directivesAdvance directives: Find: Pt: {Setting}: Doc: {Role} O    
       48765-2   Allergies O    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: O    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported O    
       10157-6   Family history O    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} O    
       10210-3   General status O    
       10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar: O    
       11369-6   History of immunizations O    
       46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role} O    
       10160-0   Medications O    
       10190-7   Mental status NarrativeMental status NarrativeMental status: Find: Pt: ^Patient: Nar: Observed O    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: O    
       11450-4   Problems O    
       47519-4   Procedures O    
       30954-2   Results O    
       10187-3   Review of systems O    
       29762-2   Social history O    
       8716-3   Vital signs O    
 

ASSOCIATED OBSERVATIONS

Definition/Description: This panel contains the recommended sections for consultation notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  72231-4   Consultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sectionsConsultation note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:    
       51847-2   Assessment+Plan R    
       51848-0   Assessment R    
       18776-5   Plan of care R    
       10164-2   History of present illness R    
       29545-1   Physical examination R    
       42349-1   Reason for referral R    
       29299-5   Reason for visit R    
       48765-2   Allergies O    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: O    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported O    
       10157-6   Family history O    
       10210-3   General status O    
       11348-0   Past medical history O    
       11369-6   History of immunizations O    
       10160-0   Medications O    
       11450-4   Problems O    
       47519-4   Procedures O    
       30954-2   Results (Diagnostic findings) O    
       10187-3   Review of systems O    
       29762-2   Social history O    
       8716-3   Vital signs O    
 

ASSOCIATED OBSERVATIONS

Definition/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).

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:    
       77599-9   Additional documentationAdditional documentationAdditional documentation: Find: Pt: {Setting}: Doc: {Role} R    
       77598-1   Externally defined clinical data elements DocumentExternally defined clinical data elements DocumentExternally defined clinical data elements: Find: Pt: {Setting}: Doc: {Role} R    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} R    
       77597-3   Orders placed DocumentOrders placed DocumentOrders placed: Find: Pt: {Setting}: Doc: {Role} R    
       18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role} R    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: R    
       77596-5   Transportation summary DocumentTransportation summary DocumentTransportation summary: Find: Pt: {Setting}: Doc: {Role} R    
       42348-3   Advance directivesAdvance directivesAdvance directives: Find: Pt: {Setting}: Doc: {Role} O    
       48765-2   Allergies R    
       51847-2   Evaluation +​ Plan noteEvaluation +​ Plan noteEvaluation+​Plan note: Find: Pt: {Setting}: Doc: {Role} R    
       51848-0   Evaluation noteEvaluation noteEvaluation note: Find: Pt: {Setting}: Doc: {Role} R    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: R    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported R    
       46240-8   History of Hospitalizations+​Outpatient visits NarrativeHistory of Hospitalizations+​Outpatient visits NarrativeHospitalizations+​Outpatient visits: Hx: Pt: ^Patient: Nar: R    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: R    
       10210-3   Physical findings of General status NarrativePhysical findings of General status NarrativePhysical findings: Find: Pt: General status: Nar: Observed R    
       61146-7   Goals NarrativeGoals NarrativeGoals: Find: Pt: ^Patient: Nar: R    
       75310-3   Health concerns DocumentHealth concerns DocumentHealth concerns: Find: Pt: ^Patient: Doc: R    
       11383-7   Patient problem outcome NarrativePatient problem outcome NarrativePatient problem outcome: Find: Pt: ^Patient: Nar: R    
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: R    
       10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar: R    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: R    
       69730-0   InstructionsInstructionsInstructions: Find: Pt: {Setting}: Doc: {Role} R    
       62387-6   Interventions NarrativeInterventions NarrativeInterventions: Find: Pt: ^Patient: Nar: R    
       46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role} R    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: R    
       10190-7   Mental status NarrativeMental status NarrativeMental status: Find: Pt: ^Patient: Nar: Observed R    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: R    
       61149-1   Objective NarrativeObjective NarrativeObjective: Find: Pt: ^Patient: Nar: R    
       48768-6   Payment sources DocumentPayment sources DocumentPayment sources: Find: Pt: ^Patient: Doc: R    
       29545-1   Physical findings NarrativePhysical findings NarrativePhysical findings: Find: Pt: ^Patient: Nar: Observed R    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported R    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} R    
       42349-1   Reason for referral (narrative)Reason for referral (narrative)Reason for referral: Find: Pt: ^Patient: Nar: R    
       29299-5   Reason for visit NarrativeReason for visit NarrativeReason for visit: Find: Pt: ^Patient: Nar: R    
       30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar: R    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported R    
       61150-9   Subjective NarrativeSubjective NarrativeSubjective: Find: Pt: ^Patient: Nar: R    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed R    
 

MEMBER OF THESE EQUIVALENCE GROUPS
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
  LG38750-2  Consultation note|ANYRole|ANYSetting
  LG50890-9  Immunology|ANYTypeOfService|ANYKindOfNote|ANYSetting

PARTS

Part Type    Part No.  Part Name   
Component   LP72311-1  Consultation note 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP345046-9  Immunology 
Fragments for synonyms   LP183649-5  note 

RELATED NAMES
  Consult note Evaluation and management note Random
  DOC.ONT Finding Visit note
  Document Findings  
  Encounter notes  
  Evaluation and management Point in time  

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/20/2019 8:58:58 AM
  Long Common Name: Immunology Consult note
  Shortname: Immunology Consult note
  Fully Specified Name: Consultation note: Find: Pt: {Setting}: Doc: Immunology
     
  Component Word Count: 2
  ID: 100495
  # of Panel Elements: 40
  Status (Raw): ACTIVE