R4 Ballot #2 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.5.0: R4 Ballot #2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Valueset-doc-section-codes.xml

Vocabulary Work GroupMaturity Level: N/ABallot Status: Informative

Raw XML (canonical form + also see XML Format Specification)

Definition for Value SetDocument Section Codes

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  <meta> 
    <lastUpdated value="2018-08-19T21:48:56.559+10:00"/> 
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  </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 
          <a href="http://loinc.org">
            <code> http://loinc.org</code> 
          </a> 
          <table class="none">
            <tr> 
              <td style="white-space:nowrap">
                <b> Code</b> 
              </td> 
              <td> 
                <b> Display</b> 
              </td> 
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10154-3.html">10154-3</a> 
              </td> 
              <td> Chief complaint Narrative - Reported</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10157-6.html">10157-6</a> 
              </td> 
              <td> History of family member diseases Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10160-0.html">10160-0</a> 
              </td> 
              <td> History of medication use Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10164-2.html">10164-2</a> 
              </td> 
              <td> History of present illness Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10183-2.html">10183-2</a> 
              </td> 
              <td> Hospital discharge medications Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10184-0.html">10184-0</a> 
              </td> 
              <td> Hospital discharge physical findings Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10187-3.html">10187-3</a> 
              </td> 
              <td> Review of systems Narrative - Reported</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10210-3.html">10210-3</a> 
              </td> 
              <td> Physical findings of General status Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10216-0.html">10216-0</a> 
              </td> 
              <td> Surgical operation note fluids Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10218-6.html">10218-6</a> 
              </td> 
              <td> Surgical operation note postoperative diagnosis Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10218-6.html">10218-6</a> 
              </td> 
              <td> Surgical operation note postoperative diagnosis Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10223-6.html">10223-6</a> 
              </td> 
              <td> Surgical operation note surgical procedure Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/10222-8.html">10222-8</a> 
              </td> 
              <td> Surgical operation note surgical complications [interpretation] Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/11329-0.html">11329-0</a> 
              </td> 
              <td> History general Narrative - Reported</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/11348-0.html">11348-0</a> 
              </td> 
              <td> History of past illness Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/11369-6.html">11369-6</a> 
              </td> 
              <td> History of immunization Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/57852-6.html">57852-6</a> 
              </td> 
              <td> Problem list Narrative - Reported</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/11493-4.html">11493-4</a> 
              </td> 
              <td> Hospital discharge studies summary Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/11535-2.html">11535-2</a> 
              </td> 
              <td> Hospital discharge Dx Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/11537-8.html">11537-8</a> 
              </td> 
              <td> Surgical drains Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/18776-5.html">18776-5</a> 
              </td> 
              <td> Plan of treatment (narrative)</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/18841-7.html">18841-7</a> 
              </td> 
              <td> Hospital consultations Document</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/29299-5.html">29299-5</a> 
              </td> 
              <td> Reason for visit Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/29545-1.html">29545-1</a> 
              </td> 
              <td> Physical findings Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/29549-3.html">29549-3</a> 
              </td> 
              <td> Medication administered Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/29554-3.html">29554-3</a> 
              </td> 
              <td> Procedure Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/29762-2.html">29762-2</a> 
              </td> 
              <td> Social history Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/30954-2.html">30954-2</a> 
              </td> 
              <td> Relevant diagnostic tests/laboratory data Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/42344-2.html">42344-2</a> 
              </td> 
              <td> Discharge diet (narrative)</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/42346-7.html">42346-7</a> 
              </td> 
              <td> Medications on admission (narrative)</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/42348-3.html">42348-3</a> 
              </td> 
              <td> Advance directives (narrative)</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/42349-1.html">42349-1</a> 
              </td> 
              <td> Reason for referral (narrative)</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/46240-8.html">46240-8</a> 
              </td> 
              <td> History of hospitalizations+History of outpatient visits Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/46241-6.html">46241-6</a> 
              </td> 
              <td> Hospital admission diagnosis Narrative - Reported</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/46264-8.html">46264-8</a> 
              </td> 
              <td> History of medical device use</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/47420-5.html">47420-5</a> 
              </td> 
              <td> Functional status assessment note</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/47519-4.html">47519-4</a> 
              </td> 
              <td> History of Procedures Document</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/48765-2.html">48765-2</a> 
              </td> 
              <td> Allergies and adverse reactions Document</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/48768-6.html">48768-6</a> 
              </td> 
              <td> Payment sources Document</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/51848-0.html">51848-0</a> 
              </td> 
              <td> Evaluation note</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/55109-3.html">55109-3</a> 
              </td> 
              <td> Complications Document</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/55122-6.html">55122-6</a> 
              </td> 
              <td> Surgical operation note implants Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/59768-2.html">59768-2</a> 
              </td> 
              <td> Procedure indications [interpretation] Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/59769-0.html">59769-0</a> 
              </td> 
              <td> Postprocedure diagnosis Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/59770-8.html">59770-8</a> 
              </td> 
              <td> Procedure estimated blood loss Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/59771-6.html">59771-6</a> 
              </td> 
              <td> Procedure implants Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/59772-4.html">59772-4</a> 
              </td> 
              <td> Planned procedure Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/59773-2.html">59773-2</a> 
              </td> 
              <td> Procedure specimens taken Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/59775-7.html">59775-7</a> 
              </td> 
              <td> Procedure disposition Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/59776-5.html">59776-5</a> 
              </td> 
              <td> Procedure findings Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/61149-1.html">61149-1</a> 
              </td> 
              <td> Objective Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/61150-9.html">61150-9</a> 
              </td> 
              <td> Subjective Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/61150-9.html">61150-9</a> 
              </td> 
              <td> Subjective Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/69730-0.html">69730-0</a> 
              </td> 
              <td> Instructions</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/8648-8.html">8648-8</a> 
              </td> 
              <td> Hospital course Narrative</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/8653-8.html">8653-8</a> 
              </td> 
              <td> Hospital Discharge instructions</td> 
              <td/>  
            </tr> 
            <tr> 
              <td> 
                <a href="http://details.loinc.org/LOINC/8716-3.html">8716-3</a> 
              </td> 
              <td> Vital signs</td> 
              <td/>  
            </tr> 
          </table> 
        </li> 
      </ul> 
    </div> 
  </text> 
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  <description value="Document section codes (LOINC codes used in CCDA sections)."/> 
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  <compose> 
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      <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> 
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      <concept> 
        <code value="10184-0"/> 
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      <concept> 
        <code value="10187-3"/> 
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      <concept> 
        <code value="10210-3"/> 
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      <concept> 
        <code value="10216-0"/> 
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      <concept> 
        <code value="10218-6"/> 
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      <concept> 
        <code value="10218-6"/> 
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      <concept> 
        <code value="10223-6"/> 
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      <concept> 
        <code value="10222-8"/> 
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      <concept> 
        <code value="11329-0"/> 
      </concept> 
      <concept> 
        <code value="11348-0"/> 
      </concept> 
      <concept> 
        <code value="11369-6"/> 
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      <concept> 
        <code value="57852-6"/> 
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      <concept> 
        <code value="11493-4"/> 
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      <concept> 
        <code value="11535-2"/> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
        <code value="42346-7"/> 
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      <concept> 
        <code value="42348-3"/> 
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      <concept> 
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      <concept> 
        <code value="46240-8"/> 
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      <concept> 
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      <concept> 
        <code value="46264-8"/> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
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      <concept> 
        <code value="51848-0"/> 
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      <concept> 
        <code value="55109-3"/> 
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      <concept> 
        <code value="55122-6"/> 
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      <concept> 
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      <concept> 
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      <concept> 
        <code value="59771-6"/> 
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      <concept> 
        <code value="59772-4"/> 
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      <concept> 
        <code value="59773-2"/> 
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      <concept> 
        <code value="59775-7"/> 
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      <concept> 
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      <concept> 
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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.