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Definition for Value SetDocument Section Codes
<ValueSet xmlns="http://hl7.org/fhir"> <id value="doc-section-codes"/> <meta> <lastUpdated value="2016-12-06T12:22:34.981+11:00"/> <profile value="http://hl7.org/fhir/StructureDefinition/valueset-shareable-definition"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <h2>Document Section Codes</h2> <div> <p>Document section codes (LOINC codes used in CCDA sections).</p> </div> <p> <b>Copyright Statement:</b> This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use. </p> <p>This value set includes codes from the following code systems:</p> <ul> <li>Include these codes as defined in http://loinc.org <table class="none"> <tr> <td> <b>Code</b> </td> <td> <b>Display</b> </td> </tr> <tr> <td>10154-3</td> <td>Chief complaint Narrative - Reported</td> <td/> </tr> <tr> <td>10157-6</td> <td>History of family member diseases Narrative</td> <td/> </tr> <tr> <td>10160-0</td> <td>History of medication use Narrative</td> <td/> </tr> <tr> <td>10164-2</td> <td>History of present illness Narrative</td> <td/> </tr> <tr> <td>10183-2</td> <td>Hospital discharge medications Narrative</td> <td/> </tr> <tr> <td>10184-0</td> <td>Hospital discharge physical findings Narrative</td> <td/> </tr> <tr> <td>10187-3</td> <td>Review of systems Narrative - Reported</td> <td/> </tr> <tr> <td>10210-3</td> <td>Physical findings of General status Narrative</td> <td/> </tr> <tr> <td>10216-0</td> <td>Surgical operation note fluids Narrative</td> <td/> </tr> <tr> <td>10218-6</td> <td>Surgical operation note postoperative diagnosis Narrative</td> <td/> </tr> <tr> <td>10218-6</td> <td>Surgical operation note postoperative diagnosis Narrative</td> <td/> </tr> <tr> <td>10223-6</td> <td>Surgical operation note surgical procedure Narrative</td> <td/> </tr> <tr> <td>10830-8</td> <td>Deprecated Surgical operation note complications</td> <td/> </tr> <tr> <td>11329-0</td> <td>History general Narrative - Reported</td> <td/> </tr> <tr> <td>11348-0</td> <td>History of past illness Narrative</td> <td/> </tr> <tr> <td>11369-6</td> <td>History of immunization Narrative</td> <td/> </tr> <tr> <td>11450-4</td> <td>Problem list - Reported</td> <td/> </tr> <tr> <td>11493-4</td> <td>Hospital discharge studies summary Narrative</td> <td/> </tr> <tr> <td>11535-2</td> <td>Hospital discharge Dx Narrative</td> <td/> </tr> <tr> <td>11537-8</td> <td>Surgical drains Narrative</td> <td/> </tr> <tr> <td>18776-5</td> <td>Plan of treatment (narrative)</td> <td/> </tr> <tr> <td>18841-7</td> <td>Hospital consultations Document</td> <td/> </tr> <tr> <td>29299-5</td> <td>Reason for visit Narrative</td> <td/> </tr> <tr> <td>29545-1</td> <td>Physical findings Narrative</td> <td/> </tr> <tr> <td>29549-3</td> <td>Medication administered Narrative</td> <td/> </tr> <tr> <td>29554-3</td> <td>Procedure Narrative</td> <td/> </tr> <tr> <td>29762-2</td> <td>Social history Narrative</td> <td/> </tr> <tr> <td>30954-2</td> <td>Relevant diagnostic tests/laboratory data Narrative</td> <td/> </tr> <tr> <td>42344-2</td> <td>Discharge diet (narrative)</td> <td/> </tr> <tr> <td>42346-7</td> <td>Medications on admission (narrative)</td> <td/> </tr> <tr> <td>42348-3</td> <td>Advance directives (narrative)</td> <td/> </tr> <tr> <td>42349-1</td> <td>Reason for referral (narrative)</td> <td/> </tr> <tr> <td>46240-8</td> <td>History of hospitalizations+History of outpatient visits Narrative</td> <td/> </tr> <tr> <td>46241-6</td> <td>Hospital admission diagnosis Narrative - Reported</td> <td/> </tr> <tr> <td>46264-8</td> <td>History of medical device use</td> <td/> </tr> <tr> <td>47420-5</td> <td>Functional status assessment note</td> <td/> </tr> <tr> <td>47519-4</td> <td>History of Procedures Document</td> <td/> </tr> <tr> <td>48765-2</td> <td>Allergies and adverse reactions Document</td> <td/> </tr> <tr> <td>48768-6</td> <td>Payment sources Document</td> <td/> </tr> <tr> <td>51848-0</td> <td>Evaluation note</td> <td/> </tr> <tr> <td>55109-3</td> <td>Complications Document</td> <td/> </tr> <tr> <td>55122-6</td> <td>Surgical operation note implants Narrative</td> <td/> </tr> <tr> <td>59768-2</td> <td>Procedure indications [interpretation] Narrative</td> <td/> </tr> <tr> <td>59769-0</td> <td>Postprocedure diagnosis Narrative</td> <td/> </tr> <tr> <td>59770-8</td> <td>Procedure estimated blood loss Narrative</td> <td/> </tr> <tr> <td>59771-6</td> <td>Procedure implants Narrative</td> <td/> </tr> <tr> <td>59772-4</td> <td>Planned procedure Narrative</td> <td/> </tr> <tr> <td>59773-2</td> <td>Procedure specimens taken Narrative</td> <td/> </tr> <tr> <td>59775-7</td> <td>Procedure disposition Narrative</td> <td/> </tr> <tr> <td>59776-5</td> <td>Procedure findings Narrative</td> <td/> </tr> <tr> <td>61149-1</td> <td>Objective Narrative</td> <td/> </tr> <tr> <td>61150-9</td> <td>Subjective Narrative</td> <td/> </tr> <tr> <td>61150-9</td> <td>Subjective Narrative</td> <td/> </tr> <tr> <td>69730-0</td> <td>Instructions</td> <td/> </tr> <tr> <td>8648-8</td> <td>Hospital course Narrative</td> <td/> </tr> <tr> <td>8653-8</td> <td>Hospital Discharge instructions</td> <td/> </tr> <tr> <td>8716-3</td> <td>Vital signs</td> <td/> </tr> </table> </li> </ul> </div> </text> <url value="http://hl7.org/fhir/ValueSet/doc-section-codes"/> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:2.16.840.1.113883.4.642.2.119"/> </identifier> <version value="1.8.0"/> <name value="Document Section Codes"/> <status value="draft"/> <experimental value="true"/> <publisher value="HL7"/> <contact> <telecom> <system value="url"/> <value value="http://hl7.org"/> </telecom> </contact> <date value="2016-12-06T12:22:34+11:00"/> <description value="Document section codes (LOINC codes used in CCDA sections)."/> <copyright value="This content from LOINC® is copyright © 1995 Regenstrief Institute, Inc. and the LOINC Committee, and available at no cost under the license at http://loinc.org/terms-of-use."/> <compose> <include> <system value="http://loinc.org"/> <concept> <code value="10154-3"/> </concept> <concept> <code value="10157-6"/> </concept> <concept> <code value="10160-0"/> </concept> <concept> <code value="10164-2"/> </concept> <concept> <code value="10183-2"/> </concept> <concept> <code value="10184-0"/> </concept> <concept> <code value="10187-3"/> </concept> <concept> <code value="10210-3"/> </concept> <concept> <code value="10216-0"/> </concept> <concept> <code value="10218-6"/> </concept> <concept> <code value="10218-6"/> </concept> <concept> <code value="10223-6"/> </concept> <concept> <code value="10830-8"/> </concept> <concept> <code value="11329-0"/> </concept> <concept> <code value="11348-0"/> </concept> <concept> <code value="11369-6"/> </concept> <concept> <code value="11450-4"/> </concept> <concept> <code value="11493-4"/> </concept> <concept> <code value="11535-2"/> </concept> <concept> <code value="11537-8"/> </concept> <concept> <code value="18776-5"/> </concept> <concept> <code value="18841-7"/> </concept> <concept> <code value="29299-5"/> </concept> <concept> <code value="29545-1"/> </concept> <concept> <code value="29549-3"/> </concept> <concept> <code value="29554-3"/> </concept> <concept> <code value="29762-2"/> </concept> <concept> <code value="30954-2"/> </concept> <concept> <code value="42344-2"/> </concept> <concept> <code value="42346-7"/> </concept> <concept> <code value="42348-3"/> </concept> <concept> <code value="42349-1"/> </concept> <concept> <code value="46240-8"/> </concept> <concept> <code value="46241-6"/> </concept> <concept> <code value="46264-8"/> </concept> <concept> <code value="47420-5"/> </concept> <concept> <code value="47519-4"/> </concept> <concept> <code value="48765-2"/> </concept> <concept> <code value="48768-6"/> </concept> <concept> <code value="51848-0"/> </concept> <concept> <code value="55109-3"/> </concept> <concept> <code value="55122-6"/> </concept> <concept> <code value="59768-2"/> </concept> <concept> <code value="59769-0"/> </concept> <concept> <code value="59770-8"/> </concept> <concept> <code value="59771-6"/> </concept> <concept> <code value="59772-4"/> </concept> <concept> <code value="59773-2"/> </concept> <concept> <code value="59775-7"/> </concept> <concept> <code value="59776-5"/> </concept> <concept> <code value="61149-1"/> </concept> <concept> <code value="61150-9"/> </concept> <concept> <code value="61150-9"/> </concept> <concept> <code value="69730-0"/> </concept> <concept> <code value="8648-8"/> </concept> <concept> <code value="8653-8"/> </concept> <concept> <code value="8716-3"/> </concept> </include> </compose> </ValueSet>
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.