10219-4

LOINC 2.82

Surgical operation note preoperative diagnosis Narrative

Operative note pre-op Dx

Definition

  • The Surgical operation note pre-operative diagnosis records the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery.

Component

  • Surgical operation note preoperative 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 pre-op Dx; P prime; Point in time; Pre-Op; 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 pre-op Dx
  • P prime
  • Point in time
  • Pre-Op
  • Random
  • Report
  • Surg
  • Surgical operation note preoperative Dx
  • Visit note