77601-3
LOINC Code
| LOINC code | 77601-3 | |
|---|---|---|
| name | ||
| description | An enhanced note is generated by a provider at the end of an office visit, consult, or home health encounter with a patient. Enhanced encounters may involve face-to-face time with the patient or may fall under the auspices of tele-medicine visits. An enhanced note includes all sections relevant to the specific visit, except for details concerning procedures, operations or imaging performed during the encounter. The document is intended to support the entire contents of the medical record related to a specific encounter with a patient for the administrative or clinical exchange with a third party. This term was created for, but not limited in use to, the Enhanced Encounter Document level template included in the HL7 Implementation Guide for CDA® Release 2: Additional CDA R2 Templates - Clinical Documents for Payers - Set 1 (CPD1), Release 1. | |
| status | TRIAL | |
Fully-Specified Name | ||
| component | Enhanced note | |
| property | Find = Finding | |
| time | Pt = Point in time: To identify measures at a point in time. This is a synonym for “spot” or “random” as applied to urine measurements. | |
| system | {Setting} | |
| scale | Doc = Document: A document that could be in many formats (XML, narrative, etc.) | |
| method | {Role} | |
Additional Names | ||
| short name | DOC.MISC; Document; Encounter; Evaluation and management; Evaluation and management note; Finding; Findings; MISC; notes; Point in time; Random; Visit note | |
Basic Attributes | ||
| class | DOC.MISC | |
| type | 2 Clinical | |
| order vs. observation | Enhanced note | |
Associated Observations | ||
LOINC codes that represent optional associated observation(s) for a clinical observation or laboratory test. A LOINC term may represent a single associated observation or panel containing several associated observations. | ||
History/Usage | ||
| first released | ||
| last updated | 2.63 | |
| last change type | MIN - change to field other than name | |
Related Names | ||
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