10218-6

LOINC 2.82

Surgical operation note postoperative diagnosis Narrative

Operative note post-op Dx

Definition

  • The Surgical operation note postoperative diagnosis records the diagnosis or diagnoses discovered or confirmed during the surgery. Often it is the same as the pre-operative diagnosis.

Component

  • Surgical operation note postoperative Dx

Specimen / system

  • ^Patient

Class

  • H&P.SURG PROC

Property

  • Imp

Scale

  • Nar

Related names

  • Diagnosis; Encounter; Evaluation and management; Evaluation and management note; H+P; H+P.SURGICAL PROCEDURES; Impression; Impression/interpretation of study; Impressions; Interp; Interpretation; Narrative; notes; Operative note; Operative note post-op Dx; P prime; Point in time; Random; Report; Surg; Visit note

Index terms

  • Diagnosis
  • Encounter
  • Evaluation and management
  • Evaluation and management note
  • H+P
  • H+P.SURGICAL PROCEDURES
  • Impression
  • Impression/interpretation of study
  • Impressions
  • Interp
  • Interpretation
  • Narrative
  • notes
  • Operative note
  • Operative note post-op Dx
  • P prime
  • Point in time
  • Random
  • Report
  • Surg
  • Surgical operation note postoperative Dx
  • Visit note