HL7/LOINC Clinical Document Ontology Implementation ...wiki.ihe-uk.org/images/0/07/HL7ClinicalDocument...Health Level Seven International (HL7). This draft standard is not an accredited

HL7/LOINC Clinical Document Ontology

Implementation Guide

(US Realm)

Draft Standard for Trial Use September 2013

Publication of this draft standard for trial use and comment has been approved by

Health Level Seven International (HL7). This draft standard is not an accredited American National Standard. The comment period for use of this draft standard shall

end 24 months from the date of publication. Suggestions for revision should be submitted at http://www.hl7.org/dstucomments/index.cfm.

Following this 24 month evaluation period, this draft standard, revised as necessary,

will be submitted to a normative ballot in preparation for approval by ANSI as an

American National Standard. Implementations of this draft standard shall be viable throughout the normative ballot process and for up to six months after publication of

the relevant normative standard.

Copyright © 2013 Health Level Seven International ® ALL RIGHTS RESERVED. The reproduction of this material in any form is strictly forbidden without the written permission of the publisher. HL7 International and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. Pat & TM Off.

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Page 2 HL7/LOINC Clinical Document Ontology Implementation Guide © 2013 Health Level Seven, Inc. All rights reserved. September 2013

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HL7/LOINC Clinical Document Ontology Implementation Guide Page 3 September 2013 © 2013 Health Level Seven, Inc. All rights reserved.

Primary Co-

Chair:

Brett Marquard

River Rock Associates

[email protected]

Primary Co-

Chair:

Calvin Beebe

Mayo Clinic

[email protected]

Primary Co-

Chair

Ted Klein

[email protected]

Primary Co-

Chair

Rob Hausam

[email protected]

Primary

Government

Sponsor

Nancy Orvis

DoD/TRICARE Management Activity

[email protected]

Primary

Government

Sponsor

Patricia Greim

DoD/Dept. of Veterans Affairs

[email protected]

Primary

Author

Erik Pupo

Deloitte Consulting LLP

[email protected]

Primary

Author

Russell Ott

Deloitte Consulting LLP

[email protected]

mailto:[email protected]









Acknowledgments

This guide was produced and developed through the joint efforts of the

Department of Defense (DOD) and Department of Veterans Affairs (VA)

The co-editors appreciate the support and sponsorship of the HL7 Structured

Documents Working Group (SDWG) and the HL7 Vocabulary Working Group.

This material contains content from SNOMED CT®

(http://www.ihtsdo.org/snomed-ct/). SNOMED CT is a registered trademark of

the International Health Terminology Standard Development Organisation

(IHTSDO).

This material contains content from LOINC® (http://loinc.org). The LOINC table,

LOINC codes, and LOINC panels and forms file are copyright © 1995-2012,

Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and

Codes (LOINC) Committee and available at no cost under the license at

http://loinc.org/terms-of-use.

http://www.ihtsdo.org/snomed-ct/

http://loinc.org/

http://loinc.org/terms-of-use


Table of Contents

1 INTRODUCTION ........................................................................................................... 11

1.1 Audience .............................................................................................................. 11

1.2 Purpose ................................................................................................................ 11

1.2.1 Problem Statement ........................................................................................... 12

1.2.2 Value Proposition for Interoperability ................................................................ 13

1.3 Scope ................................................................................................................... 13

1.4 Proposed Development Lifecycle ............................................................................ 15

1.4.1 Proposed Stakeholders for Development ............................................................ 16

1.5 Organization of This Guide ................................................................................... 16

1.6 Conformance Conventions Used in This Guide ...................................................... 17

1.7 Notes to Readers................................................................................................... 18

1.7.1 Use of Local LOINC Codes and Names .............................................................. 19

1.8 Content of the Package ......................................................................................... 19

2 GENERAL ONTOLOGY STRUCTURE ............................................................................. 20

2.1 Technical Approach .............................................................................................. 20

2.1.1 Ontological Approach ....................................................................................... 20

2.1.2 Metadata and Query Approach ......................................................................... 21

2.1.3 Ontology Extensions ......................................................................................... 22

2.1.4 Ontological Models ........................................................................................... 22

2.2 Technical Structure .............................................................................................. 22

2.2.1 Identifiers and Terms ....................................................................................... 23

2.2.2 Structure of Ontology Description ..................................................................... 23

2.2.3 Structure of Clinical Document Name ............................................................... 23

3 DOCUMENT ONTOLOGY............................................................................................... 24

3.1 Domain ................................................................................................................ 25

3.1.1 Allergy and Immunology ................................................................................... 25

3.1.2 Anesthesiology ................................................................................................. 25

3.1.3 Audiology ......................................................................................................... 26

3.1.4 Cardiology ........................................................................................................ 26

3.1.5 Chiropractic Medicine ...................................................................................... 26

3.1.6 Critical Care Medicine ...................................................................................... 26

3.1.7 Dentistry .......................................................................................................... 26

3.1.8 Dermatology ..................................................................................................... 26

3.1.9 Diabetology ...................................................................................................... 27


3.1.10 Emergency Medicine ......................................................................................... 27

3.1.11 Endocrinology .................................................................................................. 27

3.1.12 Family Practice ................................................................................................. 27

3.1.13 General Medicine.............................................................................................. 28

3.1.14 Internal Medicine ............................................................................................. 28

3.1.15 Medical Genetics .............................................................................................. 30

3.1.16 Mental Health .................................................................................................. 31

3.1.17 Multi-specialty Program .................................................................................... 31

3.1.18 Neurological Surgery ........................................................................................ 31

3.1.19 Neurology ......................................................................................................... 32

3.1.20 Nuclear Medicine .............................................................................................. 32

3.1.21 Nutrition and Dietetics ..................................................................................... 32

3.1.22 Obstetrics and Gynecology ............................................................................... 32

3.1.23 Occupational Health ......................................................................................... 33

3.1.24 Occupational Therapy ...................................................................................... 33

3.1.25 Oncology .......................................................................................................... 33

3.1.26 Ophthalmology ................................................................................................. 33

3.1.27 Optometry ........................................................................................................ 33

3.1.28 Oral Surgery .................................................................................................... 34

3.1.29 Orthopedic Surgery .......................................................................................... 34

3.1.30 Otolaryngology ................................................................................................. 34

3.1.31 Pastoral Care ................................................................................................... 34

3.1.32 Pathology ......................................................................................................... 34

3.1.33 Pediatrics ......................................................................................................... 35

3.1.34 Pharmacy ......................................................................................................... 38

3.1.35 Physical Medicine and Rehabilitation ................................................................ 38

3.1.36 Physical Therapy .............................................................................................. 39

3.1.37 Plastic Surgery ................................................................................................. 39

3.1.38 Podiatry ........................................................................................................... 39

3.1.39 Primary Care .................................................................................................... 40

3.1.40 Radiology ......................................................................................................... 40

3.1.41 Recreational Therapy ........................................................................................ 40

3.1.42 Research .......................................................................................................... 40

3.1.43 Respiratory Therapy ......................................................................................... 41

3.1.44 Rheumatology .................................................................................................. 41

3.1.45 Social Work ...................................................................................................... 41


3.1.46 Speech Pathology ............................................................................................. 41

3.1.47 Surgery ............................................................................................................ 41

3.1.48 Urology ............................................................................................................ 42

3.2 Type of Note (Kind of Document) ........................................................................... 43

3.2.1 Administrative note .......................................................................................... 43

3.2.2 Advance directive ............................................................................................. 47

3.2.3 Consultation Note ............................................................................................ 47

3.2.4 Correspondence ............................................................................................... 48

3.2.5 Counseling Note ............................................................................................... 48

3.2.6 Diagram ........................................................................................................... 48

3.2.7 Education Note ................................................................................................ 49

3.2.8 Encounter Note ................................................................................................ 49

3.2.9 Form ................................................................................................................ 50

3.2.10 Letter ............................................................................................................... 50

3.2.11 Note ................................................................................................................. 50

3.2.12 Report .............................................................................................................. 50

3.2.13 Public Health Document ................................................................................... 50

3.2.14 Restraint Note .................................................................................................. 51

3.2.15 Referral Note .................................................................................................... 51

3.3 Role ..................................................................................................................... 51

3.3.1 Assistant .......................................................................................................... 51

3.3.2 Case Manager .................................................................................................. 52

3.3.3 Clerical ............................................................................................................ 52

3.3.4 Counselor ........................................................................................................ 52

3.3.5 Hygienist .......................................................................................................... 52

3.3.6 Interdisciplinary ............................................................................................... 52

3.3.7 Medical Assistant ............................................................................................. 52

3.3.8 Nurse ............................................................................................................... 53

3.3.9 Patient ............................................................................................................. 54

3.3.10 Physician ......................................................................................................... 54

3.3.11 Student ............................................................................................................ 55

3.3.12 Technician ....................................................................................................... 56

3.3.13 Therapist ......................................................................................................... 56

3.4 Type of Setting ..................................................................................................... 56

3.4.1 Ambulance Transport ....................................................................................... 57

3.4.2 Birthing Center ................................................................................................ 57


3.4.3 Emergency Department .................................................................................... 57

3.4.4 Home Health .................................................................................................... 57

3.4.5 Hospital ........................................................................................................... 58

3.4.6 Inpatient Hospital............................................................................................. 58

3.4.7 Intensive Care Unit ........................................................................................... 58

3.4.8 Long Term Care Facility .................................................................................... 58

3.4.9 Outpatient ....................................................................................................... 59

3.4.10 Rehabilitation Hospital ..................................................................................... 60

3.4.11 Telehealth ........................................................................................................ 60

3.4.12 Telephone Encounter........................................................................................ 60

3.5 Type of Care Provided (Service) .............................................................................. 60

3.5.1 Communication ................................................................................................ 61

3.5.2 Conference ....................................................................................................... 61

3.5.3 Consultation .................................................................................................... 61

3.5.4 Individual Counseling ....................................................................................... 61

3.5.5 Group Counseling ............................................................................................ 61

3.5.6 Diagnostic Study .............................................................................................. 62

3.5.7 Education ........................................................................................................ 62

3.5.8 Evaluation and Management ............................................................................ 63

3.5.9 Evaluation and Management of a Specific Problem ............................................ 64

3.5.10 Disability Examination ..................................................................................... 65

3.5.11 Exercise Testing ............................................................................................... 81

3.5.12 Medication Management ................................................................................... 81

3.5.13 Procedure ......................................................................................................... 81

3.5.14 Referral ............................................................................................................ 82

3.5.15 Respite ............................................................................................................. 82

3.5.16 Supervisory Direction ....................................................................................... 82

3.5.17 Triage .............................................................................................................. 83

3.6 LOINC Clinical Document Ontology – Proposed ..................................................... 83

4 IMPLEMENTATION OF THE ONTOLOGY...................................................................... 106

4.1 Implementation Basics ....................................................................................... 106

4.2 Summary of Conformance Statements ................................................................ 106

4.3 Using the Ontology ............................................................................................. 106

4.3.1 Example of LOINC Ontology Usage .................................................................. 107

4.3.2 Use of Metadata for implementation ................................................................ 108

4.4 Reuse of Existing Taxonomies ............................................................................. 108


4.4.1 LOINC ............................................................................................................. 108

4.4.2 HL7 ................................................................................................................ 109

4.4.3 ABMS ............................................................................................................. 109

4.4.4 NUCC ............................................................................................................. 110

4.4.5 SNOMED-CT ................................................................................................... 110

4.5 Implementation Approaches for Document Type Representation ........................... 110

4.5.1 XML Representation ........................................................................................ 110

4.5.2 RDF Representation ........................................................................................ 111

4.5.3 JSON Representation ...................................................................................... 111

4.6 Implementation Approaches to Queries ................................................................ 111

4.6.1 Use of Existing Metadata Registries ................................................................. 111

4.6.2 Use of XD* Metadata ....................................................................................... 112

4.6.3 Use of FHIR and REST .................................................................................... 112

5 PROPOSED USE CASES FOR IMPLEMENTATION ......................................................... 114

5.1 Query using RESTful API ..................................................................................... 114

5.2 Query Examples using IHE XD* ........................................................................... 114

5.2.1 Querying within the Domain of Implementation ............................................... 114

5.2.2 Querying using the Document Type ................................................................. 114

5.2.3 Querying using the Role .................................................................................. 114

5.2.4 Querying using the Care Setting ...................................................................... 114

5.2.5 Querying using the Type of Service Provided .................................................... 114

5.3 Querying Remote Registries or Repositories .......................................................... 114

5.4 Vocabulary Considerations for SNOMED-CT ........................................................ 115

5.4.1 Populate value sets for individual dimensions .................................................. 115

5.4.2 Generate full (combinatorial) ontology .............................................................. 115

5.4.3 Map legacy LOINC codes into new ontology ...................................................... 115

5.5 Long Term Implementation Considerations .......................................................... 115

6 VALUE SET MAPPING TO ONTOLOGY .......................................................................... 116

7 REFERENCES ............................................................................................................. 117

APPENDIX A — ACRONYMS AND ABBREVIATIONS .......................................................... 118

APPENDIX B — CHANGE HISTORY ON ONTOLOGY ......................................................... 120

APPENDIX C - CONFORMANCE VERBS .............................................................................. 121

APPENDIX D - EXTENSIONS TO LOINC DOCUMENT ONTOLOGY ........................................ 123


Table of Figures

No table of figures entries found.

Table of Tables

Table 1 – LOINC Clinical Document Ontology Implementation Guide Lifecycle ............ 16

Table 2 – Stakeholders for LOINC Clinical Document Ontology ................................... 16

Table 3 – Package for LOINC Clinical Document Ontology Implementation Guide ....... 19

Table 4 – Structure of LOINC Clinical Document Ontology ......................................... 25

Table 6 – Proposed LOINC Clinical Document Types .................................................. 83

Table 7 – Mapping LOINC Clinical Document Ontology to IHE XD* Metadata ............ 112


1 IN TR OD UC T I ON

The purpose for this implementation guide is to define a LOINC Taxonomy for clinical

documents that are most commonly used by the Department of Defense (DOD) and the Department of Veterans Affairs as a foundation for the development of a taxonomy of

clinical document types.

This ontology is a conceptual and implementable structure of how clinical documents

should be arranged and available for access. Consistent with the vision of a healthcare

learning system, the need for a document taxonomy has become acute as health information exchange and interoperability requirements dictate an increased level of

data liquidity. To support the need for increased information exchange, some level of

classification is needed to identify all possible resources.

The DOD and VA wish to develop an implementation guide that will detail the taxonomy for developers, and will also include implementation guidance to facilitate queries and

retrieval of clinical documents and notes by clinicians and administrative or financial

staff. The acute need for an ontology of this nature has become apparent with the

challenges inherent to establishing interoperability between the DOD and VA medical

systems.

For example, VA physicians have expressed increasing frustration with searching

through hundreds of irregularly structured document titles in the Computerized Patient

Record System (CPRS) in Veterans Affairs (VA) medical centers.

1.1 Audience

The audiences for this implementation guide are the architects and developers of

healthcare information technology (HIT) systems in the US Realm that exchange patient

clinical data.

Business analysts and policy managers can also benefit from an understanding of the

ontology documented in this implementation guide, as it applies to multliple

implementation scenarios for use of an ontology of this type.

1.2 Purpose

The primary purpose of this implementation guide is to establish the LOINC Clinical

Document Ontology is to establish the ontology as a standard for the representation of

clinical document types, and to provide implementation guidance for using the LOINC

Clinical Document Ontology within other interoperability standards, specifically HL7

document and messaging standards.

A primary question that arises in this implementation guide is – why is an

implementation guide needed in support of an existing ontology? While the initial driver

for standardization of the LOINC Clinical Document Ontology is the DOD and VA, the

expected downstream benefits of pursuing this implementation

The purpose of this implementation guide is to support two implementation purposes:


Ability to search for specific clinical document types using a common taxonomy of clinical document names. The specific need for the taxonomy is to provide

semantics for names of clinical documents that are exchanged between health

information technology (HIT) systems

Ability to use metadata in association with a clinical document that can be

leveraged to locate specific clinical document types.

NOTE: this implementation guide does not establish a specific query mechanism for

implementers but defines metadata and the methodology for accessing that metadata.

This ensures a generic implementation framework that can be applied to specific

implementation environments.

The implementation guide format used here is meant to serve as the documented

baseline to be used going forward in maintaining a national standard for all clinical

document types. A supporting set of modeling files will be creating using OWL to show

the ontological structure and to provide as a formal model for systems to use in

implementing the ontology.

1.2.1 Problem Statement While much of the existing content and transport mechanisms for health

interoperability have started to take shape or already exist, there are still gaps in

standards to support interoperability. Many of these gaps are diligently being worked

through both standards development organizations (SDOs) as well as those

organizations responsible for managing controlled terminologies.

However, the need for an overarching, high level ―index‖ of interoperability has not yet

been achieved as a formal standard to guide interoperability efforts. Standards and

profiles have been developed based on the premise of being able to find and retrieve all

types of clinical data, without any one standard being specified for how to conduct that

search.

The concept of a ―Google‖ for healthcare information interoperability is an elusive goal,

but the idea of an ―index‖ to serve as the initial standard for finding clinical data is a

realstic goal in the short and long term. The LOINC Clinical Document Ontology has

already been established as an ontological representation of clinical data, that serves as a valuable baseline for locating clinical data. The other challenge is while the LOINC

Clinical Document Ontology already exists to serve in the role of a high level index of

clinical data, no standard has been specified by any current SDO or other organization

to serve as the index. Standards such as CDA R3 have been specified as critical for

meaningful use yet these interoperability standards are reliant on LOINC codes that

have not been formally introduced as a standard for interoperability.

This could potentially lead to a larger problem as health information is structured, but

is structured in an increasingly disparate fashion using local LOINC codes, or other

controlled terminologies that cannot be mapped to the LOINC Clinical Document

Ontology. It would also lead to challenges for patients, who may lack the level of depth to search for clinical data and would need some standard to guide them for what to

search for.

It is inherent throughout this implementation guide that the LOINC Clinical Document

Ontology is seen as the possible standard to use for querying and retrieving data based

on a clinical document type value. Many questions arise as to – if the standard already


exists, or the ontology is already documented in a tool such as RELMA, why is an

implementation guide needed? Another problem statement this implementation guide

seeks to address is exactly that challenge – that while an ontology exists, it is not documented to the level needed to support widespread implementation.

1.2.2 Value Proposition for Interoperability The primary driver for an implementatiuon guide to represent the LOINC Clinical

Document Ontology is the need to establish a formal ontological standard that can be

used for future interoperability projects that organizations such as HL7 would pursue.

An implementation guide of this type would be used in multiple clinical and

administrative contexts and would have broad reach across other standards used in the

implementation of interoperable healthcare solutions, including those established within HL7. Several examples of existing interoperability challenges exist where a

clinical document ontology would be crucial:

Because clinical decision support services are driven by the need to both collect information to generate alerts and guidelines, and the need to output these

alerts and guidelines in a standarsdized format, the use of clinical document

types would help a decision support service (DSS) to be able to locate and retrieve the crucial information needed to provide alerts and guidelines at the

point of care

Another area of focus would be quality measurement, where the use of clinical document types can be used to support the assembly of the data elements

needed to populate clinical quality measures.

Further focus is concentrated on the administrative domain of healthcare, where the need to use document types that may not be clinical in nature (specifically to support patient registration and enrollment activities, as well as eligiblity

checks) require an ontology to support administrative domains to locate

information

This implementation guide does not prescribe specific implementation vehicles for the

LOINC Clinical Document Ontology (although examples are included within this implementation guide) as a certain degree of flexibility will be necessary to ensure that

initial piloting and testing efforts of the LOINC Clinical Document Ontology can be

supported.

1.3 Scope

The scope of this implementation guide will be driven by unique constraints that are not

always prevalent in existing standards or implementation guides. Thus, scope is an

important tangible in developing this implementation guide, to ensure that what is being proposed as a standard to HL7 and to Regenstrief reuses existing work done to

date while being constrained to the specific need that the LOINC Clinical Document

Ontology is being proposed for.

The scope of this implementation guide is to document an ontology that defines clinical document types for the following functions:

• Searching for specific document types using a defined ontological structure

• Defining the metadata attributes that can be used to search the LOINC

Document Ontology


• Establishing a formal mechanism through Regenstrief (and HL7) to accept

extensions to the LOINC Clinical Document Ontology, and to promote reuse

of the LOINC Clinical Document Ontology by standards development

organizations.

The scope of implementation recognizes that previous work has already been developed

in this area, specifically the work of the HL7/LOINC Document Ontology Task Force

and the current LOINC Clinical Document Ontology, and this work serves as an

important driver and guidepost for all existing efforts.

Additional guidance is provided in support of implementing the ontology utilizing a

variety of approaches:

Using generic metadata guidance to implement the traversing of the LOINC Clinical Document Ontology

Providing implementation approaches to query documents that address the same or related problem in order for determination to be made while increasing specificity to short determination time.

Providing a formal and recognized channel for all stakeholders in health information technology and healthcare to follow for submission of LOINC

Document Ontology terms that are needed to expand the depth of the ontology

To test the scope of the implementation guide, further work was done to propose

harmonization of local LOINC codes that are used within the United States Department

of Veterans Affairs (VA) to the LOINC Clinical Document Ontology, which are included

as part of this implementation guide.

This ontology is also scoped to support descriptions of clinical documents and the hierarchy used to describe clinical document types, that will essentially produce the

elements of the LOINC Clinical Document Ontology as already defined within tools such

as RELMA. This serves several important objectives:

Identify important concepts that should be expressed in an ontology

• Establish standardized names for those concepts to be evaluated and

searchable

• Give those concepts clear, precise textual definitions drawn from existing

sources and subject to stringent peer review

• Constitute an authoritative ontology, with concepts that are: o Formally and unambiguously defined (to the extent practical) and expressed

in a language such as OWL

o Classified in a well-organized taxonomy (class hierarchy).

o Connected in meaningful relationships to be used for search and query

o Mutually consistent across any possible representation to eliminate

ambiguity • Support consistent and effective Healthcare IT software implementations, thus:

o Providing a sound basis for convenient, interoperable specification of

clinical document types, which:

stable over time).

possible.


o Achieving sound clinical decisions.

• Inform other work within HL7 workgroups

Other Healthcare IT terminologies such as SNOMED CT and the HL7 vocabularies, as

appropriate, may have additional mappings that need to be tied back to LOINC, and

these are determined to NOT be in scope for this implementation guide. Additional

scope limitations which have been noted include the following:

Aspects of HIPAA must be incorporated into the ontology to ensure that it does not violate any existing regulatory language. The implementation guide will be

reviewed with members of the HL7 Security Workgroup to ensure that HIPAA constraints are appropriately addressed, and guidance from HL7 experts is

provided.

The LOINC Document Ontology proposes support for those document types that would cover legal aspects of medical care, such as advance directives. However,

the scope of this implementation guide does NOT cover aspects of what

constitutes a legal clinical document.

Combinations that would define a letter (such as a letter provided by a primary care physician operating in the DOD care setting to a specialist operating in the VA care setting)

References that do not serve as a formal clinical document type, such as library resources, patient education material, clinical practice guidelines, and

prescription drug package inserts.

1.4 Proposed Development Lifecycle

The proposed development timeline for this ontology will occur in multiple phases to

support ongoing requirements and dependencies that are occurring

Phase 1 – Initial development

of the implementation guide The initial development of the implementation guide is

focused on using the LOINC Clinical Document

Ontology as a base implementation of clinical document types for location and retrieval of clinical

documents Phase 2 – Development of the

ontology using OWL (Protégé) Once the ontology is in development through HL7 and

LOINC, additional work will be done to also model the

ontology using OWL. This model will be developed to

support implementation of the ontology within a wide variety of infrastructures

Phase 3 – Broad stakeholder

review of the ontology The development of the implementation guide will

initially be targeted for pilot implementation within

the DOD and VA, but will require broader review from

HL7 and LOINC, as well as other stakeholders

involved in interoperability efforts. During this review,

further pilot efforts will be identified and a thorough review cycle will be scheduled with key experts within

HL7 workgroups and with leaders within Regenstrief. Phase 4 – Propose structural

enhancements to LOINC if

ontology implementation

indicates need

Based on the pilot implementation process that is

proposed, additional enhancements may then be

needed to the actual structure of the LOINC Clinical

Document Ontology, to include recommended changes to be passed to Regenstrief for consideration

at future LOINC meetings for how the LOINC Clinical

Document Ontology may require modification


Table 1 – LOINC Clinical Document Ontology Implementation Guide Lifecycle

1.4.1 Proposed Stakeholders for Development

In order to make an implementation guide for an ontology successful, the need to identify and respond to the needs of key stakeholders is absolutely critical. The concept

of making an ontology into an ―implementation guide‖ is a serious challenge that

requires broad review to ensure it is designed correctly. This implementation guide will

be an ongoing effort and guide development is anticipated to be closely coordinated with

the following groups:

HL7 Structured Documents

Working Group

The HL7 Structured Documents Workgroup is

the primary mechanism for development of the

implementation guide and serves as the main

body for initial review and improvement. This

body of experts is needed to evaluate the

usefulness of an ontology implementation guide

and the best way to represent such an ontology

within a format that can be acceptable as a

nationally adopted standard

HL7 Vocabulary Working

Group

The HL7 Vocabulary Workgroup provides

additional support and expertise to the

implementation guide development and review,

as well as a forum for any proposed vocabulary

harmonization proposals that may be necessary.

LOINC (Document Ontology

Workgroup) and Regenstrief

LOINC is expected to support the development

of the implementation guide with an additional

group of subject matter experts, and with the

additonal engagement on the implementation

guide as the primary owner of the Clinical

Document Ontology upon which the

implementation guide is based.

It is important to note that within the hierarchy

of stakeholders involved with the LOINC Clinical

Document Ontology, Regenstrief serves as the

primary body for adjudication and ownership of

the ontology that this implementation guide is

based on.

Table 2 – Stakeholders for LOINC Clinical Document Ontology

1.5 Organization of This Guide

This guide includes a set of implementation building blocks and the formal

ontology for use of a set of specific clinical document types (formally referred to

throughout as the LOINC Clinical Document Ontology) The main chapters are:


Chapter 2. General Ontology Structure. This chapter defines the structure and

technical approach for use and implementation of the LOINC Clinical Document

Ontology

Chapter 3. Document Ontology. This chapter defines each of the axes of the

LOINC Clinical Document Ontology. It also defines specific constraints for

implementation as a list of clinical document types that the ontology would

support

Chapter 4. Implementation of the Ontology. This chapter defines the

implementation approaches that are defined in this implementation guide for

using clinical document types for the querying and retrieval of information

Chapter 5. Proposed Use Cases for Implementation. This chapter defines specific

use cases for piloting and validing implementation of clinical document types as

a mechanism for the querying and retrieval of information – shown in Section

5.1 as Query Examples, with a set of query examples that show the use of the

LOINC Clinical Document Ontology to specify both a type and supporting

metadata to locate and retrieve patient and administrative information

Appendices - The Appendices include non-normative content to support

implementers of the LOINC Clinical Document Ontology. It includes a Change

Appendix summary of previous and updated clinical document types

1.6 Conformance Conventions Used in This Guide

Expectations related to conformance for the LOINC Document Ontology will differ from

other HL7 standards. The specific conformance language proposed in this

implementation guide would provide much looser levels of constraint as implementation

of the ontology would be expected to occur in other interoperability standards.

For example, a CDA implementation guide focused on newborn screening would

constrain document templates to a certain coded value within the LOINC Clinical

Document Ontology.

General conformance statements for this ontology include the following:

A conformant system SHALL encode clinical document types .

A conformant system SHOULD assign metadata in accordance with organizational-specific policy

A conformant system SHOULD process, manage, and retrieve metadata associated with clinical document types as expressed in the LOINC Clinical Document Ontology

A conformant system SHALL rely on the LOINC Clinical Document Ontology for the definitions and relationships of the terms and concepts that are necessary

for making access control decisions. (Note that the HL7 RBAC Healthcare

Permission Catalog is authoritative for definitions of terms and concepts

specified therein; the HL7 Security and Privacy Ontology reproduces those definitions verbatim, defines additional terms and concepts, and adds

relationships, especially hierarchical relationships among concepts.) This

conformance criterion MAY encompass all access control system components,

including the following:


A conformant access control system policy administration point SHALL invoke HL7 Security and Privacy Ontology terminology services to support encoding and

retrieval of applicable policies for a conformant access control system policy administration point.

b. A conformant access control system policy information point SHALL invoke HL7 Security and Privacy Ontology terminology services to support retrieval of

applicable initiator, resource, context, and request access control decision

information needed to generate an access control decision.

c. A conformant access control system policy decision point SHALL invoke HL7 Security and Privacy Ontology terminology services to support access control

decisions.

d. A conformant access control system policy enforcement point SHALL invoke HL7 Security and Privacy Ontology terminology services to support access

control enforcement within the custodian enterprise, in transit and in

intermediary systems, and in end user clients.

HL7 Security and Privacy Ontology terminology services SHOULD be invoked by means of HL7 Common Terminology Services 2 (CTS2) (5), or another suitable

service implementation for accessing the ontology content, such as a service supporting the OWL API (http://owlapi.sourceforge.net/).

HL7 Security and Privacy Ontology terminology services SHALL be invoked directly at run time, e.g., while making access control decisions, or at build time,

e.g., to suitably populate whatever data store the access control system or other

application prefers to use internally.

1.7 Notes to Readers

This document is primary; the formal OWL representation of the ontology is secondary

in the sense that this document will prevail in case of inadvertent conflict. Nonetheless,

the intent is to produce a single shared ontology for use across the HL7 constituency.

While this document serves to introduce, motivate and explain the LOINC Document

Ontology, the inherent limitations of linear text make it impossible to fully convey the richly interconnected, formal logic-based nature of the ontology itself. Examples in this

document and/or the ontology are not considered normative.

The definition of an ontology used in this guide are:

In the context of computer and information sciences, an ontology defines a set of

representational primitives with which to model a domain of knowledge or discourse.

The representational primitives are typically classes (or sets), attributes (or properties),

and relationships (or relations among class members). The definitions of the

representational primitives include information about their meaning and constraints on

their logically consistent application. In the context of database systems, ontology can be viewed as a level of abstraction of data models, analogous to hierarchical and

relational models, but intended for modeling knowledge about individuals, their

attributes, and their relationships to other individuals. Ontologies are typically specified

in languages that allow abstraction away from data structures and implementation

strategies; in practice, the languages of ontologies are closer in expressive power to first-order logic than languages used to model databases. For this reason, ontologies are

said to be at the "semantic" level, whereas database schema are models of data at the

http://owlapi.sourceforge.net/


"logical" or "physical" level. Due to their independence from lower level data models,

ontologies are used for integrating heterogeneous databases, enabling interoperability

among disparate systems, and specifying interfaces to independent, knowledge-based services. In the technology stack of the Semantic Web standards, ontologies are called

out as an explicit layer. There are now standard languages and a variety of commercial

and open source tools for creating and working with ontologies.

1.7.1 Use of Local LOINC Codes and Names

One of the largest challenges in building an implementation guide for the LOINC

Document Ontology is recognizing the need to support a large number of LOINC clinical

document types that would be designated at the local/organizational level.

The use of local codes and names would be discouraged but not forbidden based on the

text defined in this document. There is no specific implementation path by which HL7

or any other organization can specifically force conformance.

1.8 Content of the Package

The following files have been included in this implementation guide initial release

Filename Description Standards

Applicability

HL7 LOINC Clinical Document Ontology

Implementation Guide

Word Main guide for

review

Table 3 – Package for LOINC Clinical Document Ontology Implementation Guide


2 G ENE RA L ONTO LO GY ST RU CT UR E

The LOINC Document Ontology structure is based on the current LOINC Clinical

Document Ontology (CDO). There are several aspects to the ontology that are

documented within this implementation guide section, specifically:

The technical approach used in the creation of this implementation guide – how

was the ontology documented

The technical structure of the ontology, as directly drawn from the current

LOINC Clinical Document Ontology approach

2.1 Technical Approach

The principles behind balloting the current LOINC Document Ontology as a standard

are as follows:

Increase discrimination by providing greater detail regarding document type

definition within an implementation guide

Associate each document type with metadata that would be useful in a query

Allow (but not require) specification of additional detail than what is currently

part of the LOINC Clinical Document Ontology

Encourage query by property/metadata rather than query by LOINC number to

broaden use of clinical document types as a method for querying clinical data

Fully define properties to support document query API

Improve guidance on how to classify documents and define new document types

Improve descriptions and separate overloaded axis

Harmonize property value sets with reference terminologies and extended

hierarchy

Revise document type hierarchy to reflect subsumption

Map DoD and VA documents based on criteria to identify comparable

documents.

Use the axis value sets from the LOINC User Guide.

The technical approach proposed in this implementation guide has several parts needed

for implementation:

Documentation of the current LOINC Clinical Document Ontology as-is

Documentation of the use of metadata to support queries of clinical document

types defined in the LOINC Clinical Document Ontology

Mechanisms for extending the LOINC Clinical Document Ontology within the

parameters of the current Regesntrief processes

2.1.1 Ontological Approach


In this approach, the LOINC Document Ontology becomes a value set of document

types, similar to constrained value sets of document types. All subsequent value sets

that are created would use this base implementation guide to support implementation

For example, HITSP C80 includes a specific value set for document types

(2.16.840.1.113883.3.88.12.80.47 ) constrained specifically for HITSP’s puposes, and used in conjunction with an XDS affinity domain. This approach to constraining an

ontology is the expected path for implementation of the LOINC Clinicial Document

Ontology, where the ontology serves as the source terminology for all future document

types, and is managed primarily by Regenstrief with expert input from HL7.

Eventual implementation through HL7 is proposed to allow for the integration of the

LOINC Document Ontology directly into existing HL7 standards. For example, it would

be expected that conformance requirements going forward for HL7 standards and

implementation guides would include the following conformance statements:

These conformance statements would be developed in coordination with the HL7

Technical Standards Committee and the HL7 Structured Documents Working

Group, with significant input and discussion welcome from all HL7 stakeholder

bodies

2.1.2 Metadata and Query Approach

The primary purpose in developing this implementation guide would be to use the

LOINC document ontology as a tool to locate and query for clinical documents and other

forms of documented data (such as an image or a general artifact). The implementation

of the ontology and associated metadata is an important piece to driving forward with implementation of the LOINC Clinical Document Ontology.

The document ontology does not include the scope of the following:

Use of specific metadata associated with a specific approach for using clinical document types. This implementation guide DOES NOT mandate specific

conformance with a specific approach for associating metadata with LOINC codes.

Definition of specific query mechanisms to use in association with a specific clinical document type. Again, this implementation guide DOES NOT mandate

speciifc approaches for querying and retrieving clinical documents.

Instead, the approach for metadata and querying of metadata is to define the following:

Allow for specification of additional detail to query for clinical document types, but DO NOT require a specific query mechanism or specific required metadata

attributes

Support query mechanisms that allow for query by specific LOINC properties or metadata associated with a LOINC clinical document type rather than query by

specific LOINC codes.

Support additional metadata to be associated with each clinical document type that is outside the scope of the ontology and can be defined by the implementer


2.1.3 Ontology Extensions The design of the LOINC Document Ontology is focused on establishing a baseline for

all clinical document types specific to information exchange. While this is a worthy

outcome, it is well recognized that not all clinical document types would be documented

in an initial ontology that is the subject of an implementation guide. It is also not

appropriate to include a specific process or approach within an implementation guide

for the management of an underlyhing standard.

Consequently, a specific sub-ontology can easily be extended and/or further

constrained by importing it into a corresponding new sub-ontology, then adding more

classes and/or OWL restrictions involving imported classes. Moreover, specific sub-

ontologies can be replaced. For example, a national realm might choose to standardize

on a different set of clinical document types. It is thus recognized that this implementation guide SHOULD NOT constrain extensions to the LOINC Clinical

Document Ontology.

This implementation guide recognizes the established process already in place for

managing and updating the current LOINC Clinical Document Ontology. The additional

process proposed for extensions to the LOINC Clinical Document Ontology is further review by HL7 (specifically the Structured Documents and Vocabulary workgroups) to

ensure coordination and inclusion in those standards where clinical document types

are needed (for example, in a CDA R2 implementation guide that requires specification

of a specific clinicalDocumentType.

This review of extensions for all HL7 standards is proposed for the following reasons

Increase awareness and usage of the document ontology in the development of existing HL7 standards

Begin to standardize typeCode values for HL7

This section is proposed as draft pending further review and discussion among the

following groups within HL7

HL7 Vocabulary Working Group

HL7 Structured Documents Working Group (SDWG)

Hl7 Technical Standards Committee (TSC)

2.1.4 Ontological Models Central to the idea of supporting the LOINC Document Ontology is the need for an

underlying model that further explains the Clinical Document Ontology (CDO). Although not included in the immediate short-term approach for LOINC Clinical

Document Ontology implementation, the 2014 version of this implementation guide will

include a supporting OWL-based version of the LOINC Clinical Document Ontology.

To further enhance implementation of LOINC, additional work was performed to design and develop a formal ontology using OWL as the primary language for specification.

This will be included as a fully documented portion of the implementation guide.

2.2 Technical Structure


The proposed technical approach uses structure as the dominating context for the

implementation of the ontology. No changes to the current technical structure are

anticipated and no changes are directly defined in this implementation guide.

The level of the detail in the implementation guide is reflective of the detailed structure

of the underlying standard, while also providing specific implementation guidance for

how to use the LOINC Clinical Document Ontology as a mechanism to improve query

and retrieval of clinical documents. Types are established based on shared structural

properties for a specific instance of a clinical document.

2.2.1 Identifiers and Terms

The current implementaton guide uses the same identifiers and terms as those specified for the LOINC Document Ontology. The intention is not to introduce new terms that

would be unfamiliar to those who already work with the current ontology.

The only identifiers and terms that would be introduced in this implementation guide

would be identifiers and terms associated with metadata for a clinical document type.

2.2.2 Structure of Ontology Description

The structure of the ontology is designed in several pieces as part of a larger package:

The implementation guide for the ontology contains descriptive information about each class contained in the ontology and how to implement and query

these classes as a clinical document type

Each of the layers within the ontology will be modeled as an OWL file subsequent to release of the LOINC Document Ontology. The use of a package of

RDF files would then allow for the development of system designs from the ontology that would maintain class relationships and associations.

2.2.3 Structure of Clinical Document Name The structure of the clinical document name is based on the current LOINC Document Ontology and its naming structure. No changes are proposed to the structure of the

names that are used within the ontology.

This structure specifies that any document name listed in this implementation guide

must contain a Kind of Document value (as expressed through the component part) as

well as information provided through at least one of the other axes as specified in the ontology:

Property

Time

System

Scale

Method

This approach ensures that queries that are based on the document type ―display

name‖ can be executed as an alternative implementation approach, and ensures no

changes are made to the LOINC Document Ontology multi-axial approach.


3 D O CU MEN T ON TO LO GY

The LOINC Document Ontology is intended to be used as the primary source ontology

for defining valid document types, with specific use as part of application ontologies that are implemented to represent document types, such as those in an XDS affinity

domain. This will allow for the flexibility to use additional local LOINC codes if

necessary, for the description of document types that may be specific to a domain or

organization.

The goal of documenting each of the axes listed in this section is to document the current LOINC Clinical Document Ontology as a baseline ontology that can be

represented in an implementation guide format, for review by both HL7 and Regenstrief,

and to begin further phases of review for additional LOINC codes to be included as

proposed additions to the current ontology within the appropriate LOINC working

groups.

The schema that is proposed within the LOINC Clinical Document Taxonomy uses the

following structure:

• Domain

• Type of Note (referred to as Document Type)

• Role

• Type of Setting (Inpatient, Outpatient as examples)

• Type of Care Provided

This is the current structure as defined by Regenstrief within LOINC and this

implementation guide adopts the current structure specified for the LOINC Clinical

Document Ontology as is. The proposed approach used within the tables provided is

shown in the example below:

Description A description of the intended meaning for the LOINC code in the context of the Clinical Document Ontology. Wherever possible, the

implementation guide will seek to draw from the existing

LOINC_NUMBER The specific LOINC code that applies to this clinical document

type. There can be several variations of this field that are shown

but the primary field used is the current LOINC code as specified

from LOINC Clinical Document Ontology as part of LOINC 2.4

This field can include local proposed codes as part of this

implementation guide, which are proposed by organizations such

as the DOD and VA as additions to the LOINC Clinical Document

Ontology. These would be highlighted in yellow if populated

PART_NUMBER An additional level of specification in which the LOINC part

number is provided. The part number is also specified with the specific axe it pertains to.

Super Class A super class would indicate the level of this code within the

LOINC hierarchy that this particular LOINC code inherits from.

This is the core levels of the ontology. As this is an ontology, the

super class is the highest level class within the ontology that this


specific LOINC code resides in, and would specify classes at higher

levels for the root class, and classes 1 level above as the ontology

is traversed.

Notes Associated notes for the specified LOINC code. Notes can take a

wide variety of forms but are intended to represent implementation details for specific use by the implementer

Source The specific source of information used for this document type. A

primary source for many of these codes will by Regenstrief and use

of the RELMA tool.

For many codes within the ontology, there is no existing LOINC

code defined within the LOINC Clinical Document Ontology and this is noted in yellow

Table 4 – Structure of LOINC Clinical Document Ontology

3.1 Domain

Individual clinical domains are established at the top of the ontological structure to

allow for initial query functions to be implemented through traversing a clinical domain. The domains within the ontology are used to classify the subject matter domain of a

specific clinical document.

All proposed codes for this axe are drawn from the Method LOINC part. Unless

otherwise specified, all codes in this section are specific to those defined in the ―Subject

Matter Domain (SMD)‖ section of the LOINC Users Guide.

3.1.1 Allergy and Immunology

Description

PART_NUMBER LP135585-0

Super Class Method

Notes

Source LOINC Clinical Document Ontology

3.1.2 Anesthesiology

Description


Super Class Method

Notes


3.1.2.1 Pain Medicine

Description


Super Class Anesthesiology

Notes



3.1.3 Audiology

Description


Super Class Method

Notes


3.1.4 Cardiology

Description


Super Class Method

Notes


3.1.5 Chiropractic Medicine

Description


Super Class Method

Notes


3.1.6 Critical Care Medicine

Description


Super Class Method

Notes


3.1.7 Dentistry

Description


Super Class Method

Notes


3.1.8 Dermatology

Description


Super Class Method

Notes



3.1.8.1 Clinical and Laboratory Dermatological Immunology

Description

PART_NUMBER None defined – requires LOINC part

Super Class Dermatology

Notes


3.1.8.2 Pediatric Dermatology

Description


Super Class Dermatology

Notes


3.1.9 Diabetology

Description


Super Class Method

Notes


3.1.10 Emergency Medicine

Description


Super Class Method

Notes


3.1.11 Endocrinology

Description


Super Class

Notes


3.1.12 Family Practice

Description


Super Class Method

Notes



3.1.12.1 Adolescent Medicine

Description

LOINC LP134107-4

Super Class Family Practice

Notes

Source

3.1.12.2 Geriatric Medicine

Description

LOINC LP97119-9

Super Class Family Practice

Notes


3.1.13 General Medicine

Description

LOINC LP32225-2

Super Class Method

Notes


3.1.14 Internal Medicine

Description


Super Class Method

Notes


3.1.14.1 Cardiovascular Disease

Description


Super Class Internal Medicine

Notes


3.1.14.1.1 Advanced Heart Failure and Transplant Cardiology

Description


Super Class Cardiovascular Disease

Notes



3.1.14.1.2 Electrophysiology

Description


Super Class Cardiovascular Disease

Notes


3.1.14.2 Endocrinology

Description



Notes


3.1.14.3 Gastroenterology

Description



Notes


3.1.14.4 Geriatric Medicine

Description



Notes


3.1.14.5 Hematology and Oncology

Description



Notes


3.1.14.6 Infectious Disease

Description



Notes



3.1.14.7 Nephrology

Description



Notes


3.1.14.8 Pulmonary Disease

Description



Notes


3.1.14.9 Rheumatology

Description



Notes


3.1.15 Medical Genetics

Description


Super Class Method

Notes


3.1.15.1 Clinical Biochemical Genetics

Description


Super Class Medical Genetics

Notes


3.1.15.2 Clinical Genetics

Description


Super Class Medical Genetics

Notes



3.1.16 Mental Health

Description


Super Class Method

Notes


3.1.16.1 Psychiatry

Description


Super Class Mental Health

Notes


3.1.16.1.1 Child and Adolescent Psychiatry

Description


Super Class Psychiatry

Notes


3.1.16.2 Psychology

Description


Super Class Mental Health

Notes


3.1.17 Multi-specialty Program

Description


Super Class Method

Notes


3.1.18 Neurological Surgery

Description


Super Class Method

Notes



3.1.19 Neurology

Description


Super Class Method

Notes


3.1.19.1 Neurology with Special Qualifications In Child Neurology

Description


Super Class Neurology

Notes


3.1.19.2 Pain Medicine

Description


Super Class Neurology

Notes


3.1.20 Nuclear Medicine

Description


Super Class Method

Notes


3.1.21 Nutrition and Dietetics

Description


Super Class Method

Notes


3.1.22 Obstetrics and Gynecology

Description


Super Class Method

Notes



3.1.22.1 Pediatric Endocrinology

Description

LOINC LP134123-1

Super Class Obstetrics and Gynecology

Notes


3.1.23 Occupational Health

Description


Super Class Method

Notes


3.1.24 Occupational Therapy

Description


Super Class Method

Notes


3.1.25 Oncology

Description


Super Class Method

Notes


3.1.26 Ophthalmology

Description


Super Class Method

Notes


3.1.27 Optometry

Description


Super Class Method

Notes



3.1.28 Oral Surgery

Description


Super Class Method

Notes


3.1.29 Orthopedic Surgery

Description


Super Class Method

Notes


3.1.30 Otolaryngology

Description


Super Class Method

Notes


3.1.30.1 Pediatric Otolaryngology

Description


Super Class Otolaryngology

Notes


3.1.31 Pastoral Care

Description


Super Class Method

Notes


3.1.32 Pathology

Description


Super Class Method

Notes



3.1.32.1 Surgical Pathology

Description


Super Class Pathology

Notes


3.1.32.2 Blood Bank Methods

Description


Super Class Pathology

Notes


3.1.33 Pediatrics

Description


Super Class Method

Notes


3.1.33.1 Adolescent Medicine

Description


Super Class Pediatrics

Notes


3.1.33.2 Child and Adolescent Psychiatry

Description



Notes


3.1.33.3 Developmental-Behavioral Pediatrics

Description



Notes



3.1.33.4 Pediatric Transplant Hepatology

Description



Notes


3.1.33.5 Neonatal Perinatal Medicine

Description



Notes


3.1.33.6 Pediatric Cardiology

Description



Notes


3.1.33.7 Pediatric Critical Care Medicine

Description



Notes


3.1.33.8 Pediatric Dermatology

Description



Notes


3.1.33.9 Pediatric Endocrinology

Description




Notes


3.1.33.10 Pediatric Gastroenterology

Description



Notes


3.1.33.10.1 Pediatric Transplant Hepatology

Description


Super Class Pediatric Gastroenterology

Notes


3.1.33.11 Pediatric Hematology-Oncology

Description



Notes


3.1.33.12 Pediatric Infectious Diseases

Description



Notes


3.1.33.13 Pediatric Nephrology

Description



Notes


3.1.33.14 Pediatric Otolaryngology

Description




Notes


3.1.33.15 Pediatric Pulmonology

Description



Notes


3.1.33.16 Pediatric Rehabilitation Medicine

Description



Notes


3.1.33.17 Pediatric Rheumatology

Description



Notes


3.1.33.18 Pediatric Surgery

Description



Notes


3.1.34 Pharmacy

Description


Super Class Method

Notes


3.1.35 Physical Medicine and Rehabilitation


Description


Super Class Method

Notes


3.1.35.1 Kinesiotherapy

Description


Super Class Physical Medicine and Rehabilitation

Notes


3.1.35.2 Pediatric Rehabilitation Medicine

Description



Notes


3.1.35.3 Vocational Rehabilitation

Description

PART_NUMBER


Notes


3.1.36 Physical Therapy

Description


Super Class Method

Notes


3.1.37 Plastic Surgery

Description


Super Class Method

Notes


3.1.38 Podiatry


Description


Super Class Method

Notes


3.1.39 Primary Care

Description


Super Class Method

Notes


3.1.40 Radiology

Description


Super Class Method

Notes


3.1.40.1 Radiation Oncology

Description


Super Class Radiology

Notes


3.1.40.2 Interventional Radiology

Description


Super Class Radiology

Notes


3.1.41 Recreational Therapy

Description


Super Class Method

Notes


3.1.42 Research


Description


Super Class Method

Notes


3.1.43 Respiratory Therapy

Description


Super Class Method

Notes


3.1.44 Rheumatology

Description


Super Class Method

Notes


3.1.45 Social Work

Description


Super Class Method

Notes


3.1.46 Speech Pathology

Description


Super Class Method

Notes


3.1.47 Surgery

Description


Super Class Method

Notes


3.1.47.1 Pediatric Surgery


Description


Super Class Surgery

Notes


3.1.47.2 Thoracic Surgery

Description


Super Class Surgery

Notes


3.1.47.3 Transplant Surgery

Description


Super Class Surgery

Notes


3.1.47.4 Vascular Surgery

Description


Super Class Surgery

Notes


3.1.48 Urology

Description


Super Class Method

Notes


3.1.48.1 Pediatric Urology

Description


Super Class Urology

Notes



3.2 Type of Note (Kind of Document)

Classification of the note type is the second tier within the ontology and is used to find

specific document types based on information available.

The type of note specifically maps the Component axe, as specification of the Kind of

Document, and is a base axe that is combined with at least 1 other axe to produce the

LOINC clinical document type.

Unless otherwise specified, all codes in this section are specific to those defined in the ―Kind of Document‖ section of the LOINC Users Guide.

3.2.1 Administrative note

Description An administrative document addresses non-clinical topics in the

healthcare setting. These include financial documents, bills, an

account summary, contracts, employee schedules, the HIPPA

mandated notice of privacy practices. In addition, some types of

consent document fall under this category, as they deal with

purely administrative functions, such as release of records, or consenting to an inter-facility transfer. Administrative documents

and clinical documents do share some overlap, for example

physician orders for admission, discharge or transfer. LOINC_NUMBER 51851-4


Super Class Component

Notes


3.2.1.1 Against Medical Advice Note

Description

LOINC_NUMBER


Super Class Administrative Note

Notes


3.2.1.2 Agreement

Description

LOINC_NUMBER



Notes


3.2.1.3 Certificate

Description


LOINC_NUMBER



Notes


3.2.1.3.1 Birth certificate

Description LOINC_NUMBER 71230-7


Super Class Certificate

Notes


3.2.1.3.2 Death certificate

Description LOINC_NUMBER



Notes


3.2.1.3.3 Evaluation of mental and physical incapcity certificate

Description

LOINC_NUMBER



Notes


3.2.1.4 Consent

Description Used to classify any document specific to the definition of a

patient consent

LOINC_NUMBER 59284-0


Super Class Consent

Notes


3.2.1.4.1 Abortion consent

Description





Notes


3.2.1.4.2 Anesthesia consent

Description



Super Class Consent

Notes


3.2.1.4.3 Hysterectomy consent

Description



Super Class Consent

Notes


3.2.1.4.4 Organ donation consent

Description



Super Class Consent

Notes


3.2.1.4.5 Procedure consent

Description



Super Class Consent

Notes


3.2.1.4.6 Release of information consent

Description



Super Class Consent

Notes


3.2.1.4.7 Sterilization consent

Description




Super Class Consent

Notes


3.2.1.4.8 Surgical operation consent

Description



Super Class Consent

Notes


3.2.1.5 Contract

Description

LOINC_NUMBER



Notes

Source LOINC Users Guide

3.2.1.6 Health insurance card

Description




Notes


3.2.1.7 Health insurance-related form

Description




Notes


3.2.1.8 Health record cover sheet

Description




Notes



3.2.1.9 Legal document

Description




Notes


3.2.1.9.1 Power of attorney

Description




Notes


3.2.2 Advance directive

Description




Notes


3.2.2.1 Do not resuscitate

Description



Super Class Advance Directive

Notes


3.2.2.2 Living will

Description



Super Class Advance Directive

Notes


3.2.3 Consultation Note

Description Consultation note is generated by a physician or nonphysician

practitioner's (NPP) upon request for an opinion or advice from


another physician or NPP. Consultations involve face-to-face time

with the patient or telemedicine visits. A Consultation Note must

be provided to the referring physician or NPP and include the

reason for the referral, history of present illness, physical examination, and decision-making component (Assessment and

Plan).




Notes

Source Proposed by iEHR

3.2.3.1 Confirmatory Consultation Note

Description



Super Class Consultation Note

Notes


3.2.4 Correspondence

Description




Notes


3.2.5 Counseling Note

Description




Notes


3.2.5.1 Group Counseling Note

Description



Super Class Counseling Note

Notes


3.2.6 Diagram


Description

LOINC_NUMBER

PART_NUMBER


Notes


3.2.7 Education Note

Description




Notes


3.2.8 Encounter Note

Description


Super Class General Document Type

Notes Proposed by VA

Source Submitted by VA

3.2.8.1 Encounter Note- Consultation

Description


Super Class Encounter Note



3.2.8.2 Encounter Note- Counseling

Description





3.2.8.3 Encounter Note - History & Physical

Description






3.2.9 Form

Description


Super Class General Document Type

Notes

Source Proposed through this implementation guide as a new LOINC

clinical document type

3.2.10 Letter

Description




Notes


3.2.11 Note

Description




Notes


3.2.11.1 Adverse event note

Description


Super Class Note

Notes


3.2.12 Report

Description



Notes


3.2.13 Public Health Document

Description Used to classify all public health document types. Public health

documents convey information between clinicians and public health officials. For example, the CDC has an ongoing iatrogenic

infection surveillance program which uses CDA R2 to transmit


case and rate information from individual hospitals. Vital records

and quarantine orders are examples of public health documents

which are also legal documents. Finally, public health officials use

case report forms in a manner very similar to clinical research.




Notes Proposed as new higher level document type


3.2.14 Restraint Note

Description




Notes


3.2.15 Referral Note

Description A referral note is a note that is sent to a consultant for a

consultation (e.g. opinion, testing, etc). This might often be

initiated by a primary care provider seeking advice from a specialist while the overall care remains with the PCP.




Notes


3.3 Role

Role would be defined as an enumerated list to support the searching and querying of

specific clinical document types. ―Role‖ in the context of the LOINC Document Ontology

may also refer to an individuals training or professional level.

Role represents the third tier of the ontology and maps to the Method axe. Role also is

aligned to the Subject Matter Domain (SMD) which shares the same axe.

Unless otherwise specified, all codes in this section are specific to those defined in the

―Role‖ section of the LOINC Users Guide.

3.3.1 Assistant

Description

LOINC_NUMBER


Super Class Method

Notes



3.3.2 Case Manager

Description


Super Class Method

Notes


3.3.3 Clerical

Description

LOINC_NUMBER


Super Class Method

Notes


3.3.4 Counselor

Description

LOINC_NUMBER


Super Class Method

Notes


3.3.5 Hygienist

Description

LOINC_NUMBER


Super Class Method

Notes


3.3.6 Interdisciplinary

Description

LOINC_NUMBER


Super Class Method

Notes


3.3.7 Medical Assistant

Description


LOINC_NUMBER


Super Class Method

Notes


3.3.8 Nurse

Description

LOINC_NUMBER


Super Class Method

Notes


3.3.8.1 CRNA

Description

LOINC_NUMBER


Super Class Nurse

Notes


3.3.8.2 Certified Nursing Assistant

Description

LOINC_NUMBER


Super Class Nurse

Notes


3.3.8.3 Clinical Nurse Specialist

Description

LOINC_NUMBER


Super Class Nurse

Notes


3.3.8.4 Nurse Midwife

Description

LOINC_NUMBER


Super Class Nurse

Notes



3.3.8.5 Nurse Practitioner

Description

LOINC_NUMBER


Super Class Nurse

Notes


3.3.8.6 Licensed Practical Nurse

Description

LOINC_NUMBER


Super Class Nurse

Notes


3.3.8.7 Registered Nurse

Description

LOINC_NUMBER


Super Class Nurse

Notes


3.3.9 Patient

Description


Super Class Method

Notes


3.3.10 Physician

Description


Super Class Method

Notes


3.3.10.1 Physician Assistant

Description


Super Class Physician

Notes



3.3.10.2 Physician Attending

Description



Notes


3.3.10.3 Physician Consulting

Description



Notes


3.3.10.4 Physician Fellow

Description



Notes


3.3.10.5 Physician Intern

Description



Notes


3.3.10.6 Physician Resident

Description



Notes


3.3.11 Student

Description

LOINC_NUMBER


Super Class Method

Notes



3.3.11.1 Medical Student

Description


Super Class Student

Notes


3.3.11.2 Nursing Student

Description


Super Class Student

Notes


3.3.12 Technician

Description

LOINC_NUMBER


Super Class Method

Notes


3.3.13 Therapist

Description

LOINC_NUMBER


Super Class Method

Notes


3.4 Type of Setting

The establishment of setting within the ontology model is used to establish an initial

level of classification of the types of settings where clinical documents are created and

used. Setting is not meant to be analogous to location, but meant to correlate to CMS

definitions surrounding the setting in which a service is provided.

Most clinical report names would include a setting (at least at the top level) to avoid

confusion between important classes of reports. For example, an admission H&P is

usually taken to be the Hospital Admissio H & P, but it could be confused with the

nursing home H&P if not distinguished by the setting.


Within the LOINC Document Ontology, setting is not a required component of the name.

The fourth tier of the ontology maps to the System axe.


―Setting‖ section of the LOINC Users Guide.

3.4.1 Ambulance Transport

Description

LOINC_NUMBER


Super Class System

Notes


3.4.2 Birthing Center

Description

LOINC_NUMBER


Super Class System

Notes


3.4.3 Emergency Department

Description

LOINC_NUMBER


Super Class System

Notes


3.4.4 Home Health

Description


Super Class System

Notes Change from Patient’s Home


3.4.4.1 Home Health Care

Description


Super Class Home Health

Notes Display as short name HHC

Source Proposed by IEHR


3.4.5 Hospital

Description


Super Class System

Notes


3.4.5.1 Nursing Unit

Description


Super Class Hospital

Notes


3.4.6 Inpatient Hospital

Description


Super Class System

Notes


3.4.7 Intensive Care Unit

Description


Super Class Hospital Unit

Notes System


3.4.8 Long Term Care Facility

Description


Super Class System

Notes


3.4.8.1 Custodial Care Facility

Description

LOINC_NUMBER


Super Class Long Term Care Facility

Notes



3.4.8.2 Nursing Facility

Description

LOINC_NUMBER


Super Class Long Term Care Facility

Notes


3.4.8.2.1 Skilled Nursing Facility (SNF)

Description


Super Class Nursing Facility

Notes


3.4.8.2.2 Unskilled Nursing Facility (SNF)

Description


Super Class Nursing Facility

Notes


3.4.9 Outpatient

Description


Super Class System

Notes


3.4.9.1 Ambulatory Surgical Center

Description

LOINC_NUMBER


Super Class Outpatient

Notes


3.4.9.2 Office

Description

LOINC_NUMBER



Notes



3.4.9.3 Outpatient Hospital

Description

LOINC_NUMBER



Notes


3.4.9.4 Urgent Care Center

Description

LOINC_NUMBER



Notes


3.4.10 Rehabilitation Hospital

Description

LOINC_NUMBER


Super Class System

Notes


3.4.11 Telehealth

Description

LOINC_NUMBER


Super Class System

Notes


3.4.12 Telephone Encounter

Description

LOINC_NUMBER


Super Class System

Notes


3.5 Type of Care Provided (Service)


In the fifth tier of the ontology, the specific type of care provided to a patient provides

specific detail about the type of care delivered within the document type.

The fifth tier of the ontology maps to the Component axe along with the Kind of

Document.


―Kind of Document‖ section of the LOINC Users Guide.

3.5.1 Communication

Description The exchange or transmission of ideas, attitudes, or beliefs

between individuals or groups.

LOINC LP57380-5


Notes

Source National Library of Medicine, MeSH 2006

3.5.2 Conference

Description

LOINC LP72310-3


Notes


3.5.3 Consultation

Description


Super Class

Notes


3.5.4 Individual Counseling

Description


Super Class

Notes


3.5.5 Group Counseling

Description


Super Class

Notes



3.5.6 Diagnostic Study

Description



Notes


3.5.6.1 Inhalation challenge test

Description

PART_NUNBER None defined – requires LOINC part

Super Class Diagnostic Study

Notes


3.5.7 Education

Description



Notes


3.5.7.1 Discharge Instructions

Description


Super Class Education

Notes


3.5.7.1.1 Hospital Discharge Instructions

Description

LOINC LP72753-4

Super Class Discharge Instructions

Notes


3.5.7.2 Discharge Teaching

Description

LOINC None defined – requires LOINC part


Notes



3.5.7.3 Preoperative Teaching

Description

LOINC None defined – requires LOINC part


Notes


3.5.8 Evaluation and Management

Description



Notes


3.5.8.1 Annual Evaluation

Description


Super Class Evaluation and Management

Notes


3.5.8.2 Assessment

Description Used to represent all assessment notes

PART_NUMBER- LP74507-2


Notes


3.5.8.2.1 Functional Status Assessment

Description


Super Class Assessment

Notes


3.5.8.2.2 Readiness for Military Duty Assessment

Description



Notes



3.5.8.2.3 Risk Assessment and Screening

Description



Notes


3.5.8.2.3.1 Fall Risk Assessment

Description


Super Class Risk Assessment Screening

Notes


3.5.9 Evaluation and Management of a Specific Problem

Description



Notes


3.5.9.1 Evaluation and Management of Anticoagulation

Description



Notes


3.5.9.2 Evaluation and Management of Hyperlipidemia

Description



Notes


3.5.9.3 Evaluation and Management of Hypertension

Description



Notes



3.5.9.4 Evaluation and Management of Smoking Cessation

Description



Notes


3.5.10 Disability Examination

Description

PART_NUMBER

Super Class

Notes


3.5.10.1 Compensation and Pension Examination

Description

LOINC

Super Class Disability Examination

Notes


3.5.10.1.1 VA Compensation and Pension Acromegaly

Description



Super Class Compensation and Pension Examination

Notes


3.5.10.1.2 VA Compensation and Pension Aid and Attendance or Housebound Exam

Description




Notes


3.5.10.1.3 VA Compensation and Pension Arrhythmias

Description





Notes


3.5.10.1.4 VA Compensation and Pension Arteries Veins and Miscellaneous (Misc)

Description




Notes


3.5.10.1.5 VA Compensation and Pension Audio

Description




Notes


3.5.10.1.6 VA Compensation and Pension Bones

Description




Notes


3.5.10.1.7 VA Compensation and Pension Brain and Spinal Cord

Description




Notes


3.5.10.1.8 VA Compensation and Pension Chronic Fatigue Syndrome

Description





Notes


3.5.10.1.9 VA Compensation and Pension Cold Injury Protocol

Description




Notes


3.5.10.1.10 VA Compensation and Pension Cranial Nerves

Description




Notes


3.5.10.1.11 VA Compensation and Pension Cushing's Syndrome

Description




Notes


3.5.10.1.12 VA Compensation and Pension Dental and Oral

Description




Notes


3.5.10.1.13 VA Compensation and Pension Diabetes Mellitus

Description




Notes



3.5.10.1.14 VA Compensation and Pension Digestive Conditions

Description




Notes


3.5.10.1.15 VA Compensation and Pension Ear Disease

Description




Notes


3.5.10.1.16 VA Compensation and Pension Eating Disorders

Description




Notes


3.5.10.1.17 VA Compensation and Pension Endocrine Diseases

Description




Notes


3.5.10.1.18 VA Compensation and Pension Epilepsy and Narcolepsy

Description




Notes



3.5.10.1.19 VA Compensation and Pension Esophagus and Hiatal Hernia

Description




Notes


3.5.10.1.20 VA Compensation and Pension Eye

Description




Notes


3.5.10.1.21 VA Compensation and Pension Feet

Description




Notes


3.5.10.1.22 VA Compensation and Pension Fibromyalgia

Description




Notes


3.5.10.1.23 VA Compensation and Pension General Medical

Description




Notes


3.5.10.1.24 VA Compensation and Pension Genitourinary


Description




Notes


3.5.10.1.25 VA Compensation and Pension Gynecological Conditions and Disorders of

the Breast

Description




Notes


3.5.10.1.26 VA Compensation and Pension Hand Thumb and Fingers

Description




Notes


3.5.10.1.27 VA Compensation and Pension Heart

Description




Notes


3.5.10.1.28 VA Compensation and Pension Hemic Disorders

Description




Notes



3.5.10.1.29 VA Compensation and Pension Human Immunodeficiency Virus (HIV)-

Related Illness

Description




Notes


3.5.10.1.30 VA Compensation and Pension Hypertension

Description




Notes


3.5.10.1.31 VA Compensation and Pension Infectious Immune and Nutritional

Disabilities

Description




Notes


3.5.10.1.32 VA Compensation and Pension Intestines

Description




Notes


3.5.10.1.33 VA Compensation and Pension Liver Gall Bladder and Pancreas

Description




Notes


3.5.10.1.34 VA Compensation and Pension Lymphatic Disorders

Description





Notes


3.5.10.1.35 VA Compensation and Pension Mental Disorders

Description




Notes


3.5.10.1.36 VA Compensation and Pension Mouth Lips and Tongue

Description




Notes


3.5.10.1.37 VA Compensation and Pension Muscles

Description




Notes


3.5.10.1.38 VA Compensation and Pension Neurological Disorders

Description




Notes


3.5.10.1.39 VA Compensation and Pension Nose Sinus Larynx and Pharynx

Description




Notes



3.5.10.1.40 VA Compensation and Pension Peripheral Nerves

Description




Notes


3.5.10.1.41 VA Compensation and Pension Post Traumatic Stress Disorder (PTSD) Initial Evaluation

Description




Notes


3.5.10.1.42 VA Compensation and Pension Post Traumatic Stress Disorder (PTSD)

Review

Description




Notes


3.5.10.1.43 VA Compensation and Pension Prisoner of War Protocol

Description




Notes


3.5.10.1.44 VA Compensation and Pension Pulmonary Tuberculosis and Mycobacterial

Diseases

Description




Notes



3.5.10.1.45 VA Compensation and Pension Rectum and Anus

Description




Notes


3.5.10.1.46 VA Compensation and Pension Residuals of Amputations

Description




Notes


3.5.10.1.47 VA Compensation and Pension Respiratory Diseases

Description




Notes


3.5.10.1.48 VA Compensation and Pension Respiratory - Obstructive Restrictive and

Interstitial

Description




Notes


3.5.10.1.49 VA Compensation and Pension Scars

Description




Notes



3.5.10.1.50 VA Compensation and Pension Sense of Smell and Taste

Description




Notes


3.5.10.1.51 VA Compensation and Pension Skin Diseases

Description




Notes


3.5.10.1.52 VA Compensation and Pension Spine

Description




Notes


3.5.10.1.53 VA Compensation and Pension Stomach Duodenum and Peritoneal

Adhesions

Description




Notes


3.5.10.1.54 VA Compensation and Pension Thyroid and Parathyroid Diseases

Description




Notes


3.5.10.2 History and Physical


Description

LOINC_NUMBER



Notes


3.5.10.2.1 Admission History and Physical

Description

LOINC_NUMBER


Super Class History and Physical

Notes


3.5.10.2.2 Comprehensive History and Physical

Description

LOINC_NUMBER



Notes


3.5.10.2.3 Labor and Delivery Admission History and Physical

Description

LOINC_NUMBER



Notes


3.5.10.2.4 Targeted History and Physical

Description

LOINC_NUMBER



Notes


3.5.10.3 Initial Evaluation

Description

LOINC_NUMBER



Notes



3.5.10.3.1 Admission Evaluation

Description

LOINC_NUMBER


Super Class Initial Evaluation

Notes


3.5.10.3.2 Admission History and Physical

Description

LOINC_NUMBER


Super Class Initial Evaluation

Notes


3.5.10.4 Plan

Description

LOINC_NUMBER



Notes


3.5.10.4.1 Asthma Action Plan

Description



Super Class Plan

Notes


3.5.10.4.2 Care Plan

Description



Super Class Plan

Notes


3.5.10.4.3 Treatment Plan

Description

LOINC_NUMBER


Super Class Plan


Notes


3.5.10.5 Restraint

Description




Notes


3.5.10.6 Subsequent Evaluation

Description

LOINC_NUMBER



Notes


3.5.10.6.1 Progress Note

Description

LOINC_NUMBER


Super Class Subsequent Evaluation

Notes


3.5.10.7 Surgical Operation

Description




Notes


3.5.10.8 Summarization

Description




Notes



3.5.10.8.1 Antepartum Summary

Description



Super Class Summarization

Notes


3.5.10.8.2 Discharge Note

Description

LOINC_NUMBER



Notes


3.5.10.8.3 Discharge Plan

Description

LOINC_NUMBER



Notes


3.5.10.8.4 Discharge Summary

Description

LOINC_NUMBER



Notes


3.5.10.8.5 Maternal Discharge Summary

Description

LOINC_NUMBER



Notes


3.5.10.8.6 Labor and Delivery Summary

Description

LOINC_NUMBER




Notes


3.5.10.8.7 Summarization of Episode

Description

LOINC_NUMBER



Notes


3.5.10.8.8 Summary of Death

Description

LOINC_NUMBER



Notes


3.5.10.8.9 Transfer Summarization

Description

LOINC_NUMBER



Notes


3.5.10.9 Transplant Candidate Evaluation

Description

LOINC_NUMBER



Notes


3.5.10.10 Transplant Donor Evaluation

Description

LOINC_NUMBER



Notes



3.5.10.11 Well Child Visit

Description

LOINC_NUMBER



Notes


3.5.11 Exercise Testing

Description



Notes


3.5.12 Medication Management

Description


PART_NUMBER


Notes


3.5.12.1 Medication Reconciliation

Description

LOINC_NUMBER


Super Class Medication Management

Notes


3.5.13 Procedure

Description

LOINC_NUMBER



Notes


3.5.13.1 Interventional Procedure

Description


PART_NUMBER


Super Class Procedure

Notes


3.5.13.2 Pathology Procedure

Description


PART_NUMBER

Super Class Procedure

Notes


3.5.13.2.1 Autopsy

Description

LOINC _NUMBER 18743-5

Super Class Pathology Procedure

Notes


3.5.14 Referral

Description



Notes


3.5.14.1 Transfer of Care Referral

Description


Super Class Referral

Notes


3.5.15 Respite

Description



Notes


3.5.16 Supervisory Direction

Description




Notes


3.5.17 Triage

Description



Notes


3.6 LOINC Clinical Document Ontology – Proposed

To support the 5 axes defined in this ontology, a proposed list of clinical document

types is defined in this implementation guide, as derived from the current LOINC

Clinical Document Ontology and standard rules that exist through the LOINC Users

Guide in defining document types. It is recognized that potential combinations dictated

by the ontology can stretch to almost 2000 different combinations so this list is

proposed as a constrained version that would be recommended as the standard list,

that can then be extended per the rules defined in Appendix D of this implementation

guide

Parent Part Part Definition LOINC ID Document Type (LOINC LONG_COMMON_NAME)

LP73895-2 Abortion consent 52027-0 Abortion consent

LP73899-4 Administrative note 51851-4 Administrative note

LP72056-2 Admission evaluation note 67851-6 Admission evaluation note

LP72056-2 Admission evaluation note 68471-2 Cardiovascular disease Hospital Admission evaluation note

LP72056-2 Admission evaluation note 68483-7 Cardiovascular disease.medical student Hospital Admission evaluation note

LP72056-2 Admission evaluation note 64058-1 Critical Care Medicine Hospital Admission evaluation note

LP72056-2 Admission evaluation note 64070-6 Critical care medicine.medical student Hospital Admission evaluation note

LP72056-2 Admission evaluation note 68552-9 Emergency medicine Emergency department Admission evaluation note

LP72056-2 Admission evaluation note 64053-2 General medicine Hospital Admission evaluation note

LP72056-2 Admission evaluation note 64054-0 General medicine.medical student Hospital Admission evaluation note

LP72056-2 Admission evaluation note 34862-3 General medicine.physician attending Hospital Admission evaluation note

LP72056-2 Admission evaluation note 67852-4 Hospital Admission evaluation note

LP72056-2 Admission evaluation note 34744-3 Nurse Admission evaluation note


LP72056-2 Admission evaluation note 64062-3 Pulmonary disease Hospital Admission evaluation note

LP72056-2 Admission evaluation note 64078-9 Pulmonary disease.medical student Hospital Admission evaluation note

LP72056-2 Admission evaluation note 34873-0 Surgery Admission evaluation note

LP72056-2 Admission evaluation note 64066-4 Surgery.medical student Hospital Admission evaluation note

LP72056-2 Admission evaluation note 64060-7 Thoracic surgery Hospital Admission evaluation note

LP72056-2 Admission evaluation note 64074-8 Thoracic surgery.medical student Hospital Admission evaluation note

LP57379-7 Admission history and physical note 51849-8 Admission history and physical note

LP57379-7 Admission history and physical note 34094-3

Cardiovascular disease Hospital Admission history and physical note

LP57379-7 Admission history and physical note 34763-3 General medicine Admission history and physical note

LP57379-7 Admission history and physical note 47039-3 Hospital Admission history and physical note

LP102490-2 Anesthesia consent 61359-6 Anesthesia consent Document Patient

LP96925-0 Antepartum summary note 57055-6 Antepartum summary note

LP74507-2 Assessment note 51848-0 Assessment note

LP74507-2 Assessment note 64064-9 Pastoral care Hospital Assessment note

LP74507-2 Assessment note 68814-3 Pediatrics Assessment note

LP73922-4 Autopsy report 18743-5 Autopsy report

LP149090-5 Birth certificate 71230-7 Birth certificate Document

LP57380-5 Communication note 47049-2 Non-patient Communication note

LP72307-9 Comprehensive history and physical note 34095-0 Comprehensive history and physical note

LP72307-9 Comprehensive history and physical note 34096-8 Nursing facility Comprehensive history and physical note

LP72310-3 Conference evaluation note 34098-4 Conference evaluation note

LP72310-3 Conference evaluation note 34097-6 Nursing facility Conference evaluation note

LP57349-0 Confirmatory consultation note 47040-1 Consultation 2nd opinion

LP57349-0 Confirmatory consultation note 47041-9 Hospital Consultation 2nd opinion

LP57349-0 Confirmatory consultation note 24611-6 Outpatient Consultation 2nd opinion

LP100037-3 Consent 59284-0 Consent Document Patient

LP72311-1 Consultation note 68619-6 Adolescent medicine Hospital Consult note

LP72311-1 Consultation note 68633-7 Allergy and immunology Hospital Consult note

LP72311-1 Consultation note 34749-2 Anesthesiology Outpatient Consult note

LP72311-1 Consultation note 68639-4 Audiology Hospital Consult note

LP72311-1 Consultation note 34099-2 Cardiovascular disease Consult note


LP72311-1 Consultation note 68486-0 Cardiovascular disease.medical student Hospital Consult note

LP72311-1 Consultation note 68648-5 Child and adolescent psychiatry Hospital Consult note

LP72311-1 Consultation note 68651-9 Clinical biochemical genetics Hospital Consult note

LP72311-1 Consultation note 68661-8 Clinical genetics Hospital Consult note

LP72311-1 Consultation note 11488-4 Consult note

LP72311-1 Consultation note 64072-2 Critical care medicine.medical student Hospital Consult note

LP72311-1 Consultation note 34756-7 Dentistry Consult note

LP72311-1 Consultation note 34771-6 Deprecated General surgery Consult note

LP72311-1 Consultation note 34758-3 Dermatology Consult note

LP72311-1 Consultation note 68551-1 Dermatology Hospital Consult note

LP72311-1 Consultation note 68670-9 Developmental-behavioral pediatrics Hospital Consult note

LP72311-1 Consultation note 34760-9 Diabetology Consult note

LP72311-1 Consultation note 51846-4 Emergency department Consult note

LP72311-1 Consultation note 34879-7 Endocrinology Consult note

LP72311-1 Consultation note 34761-7 Gastroenterology Consult note

LP72311-1 Consultation note 34764-1 General medicine Consult note

LP72311-1 Consultation note 34101-6 General medicine Outpatient Consult note

LP72311-1 Consultation note 64056-5 General medicine.medical student Hospital Consult note

LP72311-1 Consultation note 34776-5 Gerontology Consult note

LP72311-1 Consultation note 34779-9 Hematology and oncology Consult note

LP72311-1 Consultation note 34104-0 Hospital Consult note

LP72311-1 Consultation note 34781-5 Infectious disease Consult note

LP72311-1 Consultation note 34100-8 Intensive care unit Consult note

LP72311-1 Consultation note 72555-6 Interventional radiology Consult note

LP72311-1 Consultation note 34783-1 Kinesiotherapy Consult note

LP72311-1 Consultation note 51854-8 Long term care facility Consult note

LP72311-1 Consultation note 34785-6 Mental health Consult note

LP72311-1 Consultation note 68681-6 Multi-specialty program Hospital Consult note

LP72311-1 Consultation note 68685-7 Neonatal perinatal medicine Hospital Consult note

LP72311-1 Consultation note 34795-5 Nephrology Consult note

LP72311-1 Consultation note 34798-9 Neurological surgery Consult note

LP72311-1 Consultation note 68694-9 Neurological surgery Hospital Consult note

LP72311-1 Consultation note 34797-1 Neurology Consult note

LP72311-1 Consultation note 68705-3 Neurology w special qualifications in child neuro Hospital Consult note

LP72311-1 Consultation note 34800-3 Nutrition and dietetics Consult note

LP72311-1 Consultation note 34777-3 Obstetrics and Gynecology Consult note

LP72311-1 Consultation note 68566-9 Obstetrics and Gynecology Hospital Consult note

LP72311-1 Consultation note 34803-7 Occupational health Consult note


LP72311-1 Consultation note 34855-7 Occupational therapy Consult note

LP72311-1 Consultation note 68570-1 Occupational therapy Hospital Consult note

LP72311-1 Consultation note 34805-2 Oncology Consult note

LP72311-1 Consultation note 34807-8 Ophthalmology Consult note

LP72311-1 Consultation note 68575-0 Ophthalmology Hospital Consult note

LP72311-1 Consultation note 34810-2 Optometry Consult note

LP72311-1 Consultation note 34812-8 Oromaxillofacial surgery Consult note

LP72311-1 Consultation note 68584-2 Orthopedic surgery Hospital Consult note

LP72311-1 Consultation note 34814-4 Orthopedics Consult note

LP72311-1 Consultation note 34816-9 Otorhinolaryngology Consult note

LP72311-1 Consultation note 51845-6 Outpatient Consult note

LP72311-1 Consultation note 68716-0 Pain medicine Hospital Consult note

LP72311-1 Consultation note 68469-6 Pastoral care Hospital Consult note

LP72311-1 Consultation note 60570-9 Pathology Consult note

LP72311-1 Consultation note 68727-7 Pediatric cardiology Hospital Consult note

LP72311-1 Consultation note 68892-9 Pediatric dermatology Hospital Consult note

LP72311-1 Consultation note 68897-8 Pediatric endocrinology Hospital Consult note

LP72311-1 Consultation note 68746-7 Pediatric gastroenterology Hospital Consult note

LP72311-1 Consultation note 68757-4 Pediatric hematology-oncology Hospital Consult note

LP72311-1 Consultation note 68765-7 Pediatric infectious diseases Hospital Consult note

LP72311-1 Consultation note 68869-7 Pediatric nephrology Hospital Consult note

LP72311-1 Consultation note 68874-7 Pediatric otolaryngology Hospital Consult note

LP72311-1 Consultation note 68787-1 Pediatric pulmonology Hospital Consult note

LP72311-1 Consultation note 68879-6 Pediatric rheumatology Hospital Consult note

LP72311-1 Consultation note 68802-8 Pediatric surgery Hospital Consult note

LP72311-1 Consultation note 68864-8 Pediatric transplant hepatology Hospital Consult note

LP72311-1 Consultation note 68812-7 Pediatric urology Hospital Consult note

LP72311-1 Consultation note 68821-8 Pediatrics Hospital Consult note

LP72311-1 Consultation note 34820-1 Pharmacy Consult note

LP72311-1 Consultation note 68586-7 Pharmacy Hospital Consult note

LP72311-1 Consultation note 34822-7 Physical medicine and rehabilitation Consult note

LP72311-1 Consultation note 34824-3 Physical therapy Consult note

LP72311-1 Consultation note 68590-9 Physical therapy Hospital Consult note

LP72311-1 Consultation note 34826-8 Plastic surgery Consult note

LP72311-1 Consultation note 68597-4 Plastic surgery Hospital Consult note

LP72311-1 Consultation note 34828-4 Podiatry Consult note

LP72311-1 Consultation note 68837-4 Primary care Hospital Consult note

LP72311-1 Consultation note 34788-0 Psychiatry Consult note

LP72311-1 Consultation note 34102-4 Psychiatry Hospital Consult note

LP72311-1 Consultation note 34791-4 Psychology Consult note

LP72311-1 Consultation note 34103-2 Pulmonary Consult note


LP72311-1 Consultation note 64080-5 Pulmonary disease.medical student Hospital Consult note

LP72311-1 Consultation note 34831-8 Radiation oncology Consult note

LP72311-1 Consultation note 34833-4 Recreational therapy Consult note

LP72311-1 Consultation note 34835-9 Rehabilitation Consult note

LP72311-1 Consultation note 34837-5 Respiratory therapy Consult note

LP72311-1 Consultation note 34839-1 Rheumatology Consult note

LP72311-1 Consultation note 34841-7 Social work Consult note

LP72311-1 Consultation note 68846-5 Speech-language pathology Hospital Consult note

LP72311-1 Consultation note 34845-8 Speech-language pathology+Audiology Consult note

LP72311-1 Consultation note 34847-4 Surgery Consult note

LP72311-1 Consultation note 64068-0 Surgery.medical student Hospital Consult note

LP72311-1 Consultation note 34849-0 Thoracic surgery Consult note

LP72311-1 Consultation note 64076-3 Thoracic surgery.medical student Hospital Consult note

LP72311-1 Consultation note 68852-3 Transplant surgery Hospital Consult note

LP72311-1 Consultation note 34851-6 Urology Consult note

LP72311-1 Consultation note 34853-2 Vascular surgery Consult note

LP57350-8 Counseling note 47042-7 Counseling note

LP57350-8 Counseling note 34864-9 Mental health Counseling note

LP57350-8 Counseling note 34869-8 Pharmacy Counseling note

LP57350-8 Counseling note 34865-6 Psychiatry Counseling note

LP57350-8 Counseling note 34866-4 Psychology Counseling note

LP57350-8 Counseling note 34872-2 Social work Counseling note

LP116197-7 Death certificate 64297-5 Death certificate

LP134108-2 Diagnostic study note 68611-3 Adolescent medicine Diagnostic study note

LP134108-2 Diagnostic study note 68625-3 Allergy and immunology Diagnostic study note

LP134108-2 Diagnostic study note 68635-2 Audiology Diagnostic study note

LP134108-2 Diagnostic study note 68640-2 Audiology Hospital Diagnostic study note

LP134108-2 Diagnostic study note 68641-0 Child and adolescent psychiatry Diagnostic study note

LP134108-2 Diagnostic study note 68652-7 Clinical genetics Diagnostic study note

LP134108-2 Diagnostic study note 70004-7 Diagnostic study note

LP134108-2 Diagnostic study note 68673-3 Multi-specialty program Diagnostic study note

LP134108-2 Diagnostic study note 68687-3 Neurological surgery Diagnostic study note

LP134108-2 Diagnostic study note 68556-0 Neurology Diagnostic study note

LP134108-2 Diagnostic study note 68696-4 Neurology w special qualifications in child neuro Diagnostic study note

LP134108-2 Diagnostic study note 68706-1 Neurology w special qualifications in child neuro Hospital Diagnostic study note

LP134108-2 Diagnostic study note 68557-8 Obstetrics and Gynecology Diagnostic study note

LP134108-2 Diagnostic study note 68577-6 Orthopedic surgery Diagnostic study note

LP134108-2 Diagnostic study note 68708-7 Pain medicine Diagnostic study note

LP134108-2 Diagnostic study note 68718-6 Pediatric cardiology Diagnostic study note


LP134108-2 Diagnostic study note 68748-3 Pediatric hematology-oncology Diagnostic study note

LP134108-2 Diagnostic study note 68767-3 Pediatric nephrology Diagnostic study note

LP134108-2 Diagnostic study note 68778-0 Pediatric pulmonology Diagnostic study note

LP134108-2 Diagnostic study note 68788-9 Pediatric pulmonology Hospital Diagnostic study note

LP134108-2 Diagnostic study note 68794-7 Pediatric surgery Diagnostic study note

LP134108-2 Diagnostic study note 68855-6 Pediatric transplant hepatology Diagnostic study note

LP134108-2 Diagnostic study note 68804-4 Pediatric urology Diagnostic study note

LP134108-2 Diagnostic study note 68822-6 Pediatrics Hospital Diagnostic study note

LP134108-2 Diagnostic study note 68604-8 Radiology Diagnostic study note

LP156982-3 Digital photographic image 72170-4 Digital photographic image Unspecified body region Document

LP101193-3 Discharge instructions 60280-5 Discharge instructions Emergency department Document

LP101193-3 Discharge instructions 60281-3 Discharge instructions Inpatient hospital Document

LP72467-1 Discharge summarization note 68612-1 Adolescent medicine Discharge summary

LP72467-1 Discharge summarization note 68626-1 Allergy and immunology Discharge summary

LP72467-1 Discharge summarization note 68642-8 Child and adolescent psychiatry Discharge summary

LP72467-1 Discharge summarization note 68653-5 Clinical genetics Discharge summary

LP72467-1 Discharge summarization note 29761-4 Dentist Discharge summary

LP72467-1 Discharge summarization note 68663-4 Developmental-behavioral pediatrics Discharge summary

LP72467-1 Discharge summarization note 18842-5 Discharge summary

LP72467-1 Discharge summarization note 59258-4 Emergency department Discharge summary

LP72467-1 Discharge summarization note 34105-7 Hospital Discharge summary

LP72467-1 Discharge summarization note 68674-1 Multi-specialty program Discharge summary

LP72467-1 Discharge summarization note 68688-1 Neurological surgery Discharge summary

LP72467-1 Discharge summarization note 68697-2 Neurology w special qualifications in child neuro Discharge summary

LP72467-1 Discharge summarization note 34745-0 Nurse Discharge summary

LP72467-1 Discharge summarization note 68558-6 Obstetrics and Gynecology Discharge summary

LP72467-1 Discharge summarization note 68572-7 Ophthalmology Discharge summary

LP72467-1 Discharge summarization note 68578-4 Orthopedic surgery Discharge summary

LP72467-1 Discharge summarization note 68709-5 Pain medicine Discharge summary

LP72467-1 Discharge summarization note 68719-4 Pediatric cardiology Discharge summary

LP72467-1 Discharge summarization note 68733-5 Pediatric endocrinology Discharge summary

LP72467-1 Discharge summarization note 68738-4 Pediatric gastroenterology Discharge summary

LP72467-1 Discharge summarization note 68749-1 Pediatric hematology-oncology Discharge summary

LP72467-1 Discharge summarization note 68768-1 Pediatric nephrology Discharge summary

LP72467-1 Discharge summarization note 68773-1 Pediatric otolaryngology Discharge summary

LP72467-1 Discharge summarization note 68779-8 Pediatric pulmonology Discharge summary

LP72467-1 Discharge summarization note 68795-4 Pediatric surgery Discharge summary

LP72467-1 Discharge summarization note 68856-4 Pediatric transplant hepatology Discharge summary


LP72467-1 Discharge summarization note 68805-1 Pediatric urology Discharge summary

LP72467-1 Discharge summarization note 68815-0 Pediatrics Discharge summary

LP72467-1 Discharge summarization note 68823-4 Pediatrics Hospital Discharge summary

LP72467-1 Discharge summarization note 28655-9 Physician attending Discharge summary

LP72467-1 Discharge summarization note 11490-0 Physician Discharge summary

LP72467-1 Discharge summarization note 34106-5 Physician Hospital Discharge summary

LP72467-1 Discharge summarization note 68591-7 Plastic surgery Discharge summary

LP72467-1 Discharge summarization note 68831-7 Primary care Discharge summary

LP72467-1 Discharge summarization note 59259-2 Psychiatry Discharge summary

LP72467-1 Discharge summarization note 68841-6 Speech-language pathology Discharge summary

LP72530-6 Education note 34897-9 Diabetology Education note

LP72530-6 Education note 34895-3 Education note

LP72530-6 Education note 67854-0 Gerontology Education note

LP72530-6 Education note 34902-7 Gerontology Outpatient Education note

LP72530-6 Education note 34107-3 Home health Education note

LP72530-6 Education note 68477-9 Nurse Hospital Education note

LP72530-6 Education note 67855-7 Outpatient Education note

LP72530-6 Education note 68605-5 Recreational therapy Hospital Education note

LP133904-5 Evaluation and management of anticoagulation note 34856-5 Evaluation and management of anticoagulation note

LP135361-6 Evaluation and management of hyperlipidemia note 34859-9 Evaluation and management of hyperlipidemia

LP135362-4 Evaluation and management of hypertension note 34860-7 Evaluation and management of hypertension

LP135363-2 Evaluation and management of smoking cessation note 70005-4 Evaluation and management of smoking cessation

LP135363-2 Evaluation and management of smoking cessation note 64142-3

Hospital Evaluation and management of smoking cessation

LP57351-6 Group counseling note 47043-5 Group counseling note

LP57351-6 Group counseling note 34114-9 Hospital Group counseling note

LP57351-6 Group counseling note 34787-2 Mental health Group counseling note

LP57351-6 Group counseling note 34790-6 Psychiatry Group counseling note

LP57351-6 Group counseling note 34793-0 Psychology Group counseling note

LP57351-6 Group counseling note 34843-3 Social work Group counseling note

LP116194-4 Health insurance card 64290-0 Health insurance card

LP116195-1 Health insurance-related form 64291-8 Health insurance-related form

LP116193-6 Health record cover sheet 64289-2 Health record cover sheet

LP72701-3 History and physical note 68614-7 Adolescent medicine History and physical note

LP72701-3 History and physical note 68622-0 Advanced heart failure and transplant cardiology History and physical note

LP72701-3 History and physical note 68628-7 Allergy and immunology History and physical note

LP72701-3 History and physical note 68637-8 Audiology History and physical note


LP72701-3 History and physical note 68644-4 Child and adolescent psychiatry History and physical note

LP72701-3 History and physical note 68655-0 Clinical genetics History and physical note

LP72701-3 History and physical note 68665-9 Developmental-behavioral pediatrics History and physical note

LP72701-3 History and physical note 34117-2 History and physical note

LP72701-3 History and physical note 34115-6 Medical student Hospital History and physical note

LP72701-3 History and physical note 68676-6 Multi-specialty program History and physical note

LP72701-3 History and physical note 68683-2 Neonatal perinatal medicine History and physical note

LP72701-3 History and physical note 68690-7 Neurological surgery History and physical note

LP72701-3 History and physical note 68699-8 Neurology w special qualifications in child neuro History and physical note

LP72701-3 History and physical note 67856-5 Nursing facility History and physical note

LP72701-3 History and physical note 68560-2 Obstetrics and Gynecology History and physical note

LP72701-3 History and physical note 68573-5 Ophthalmology History and physical note

LP72701-3 History and physical note 68580-0 Orthopedic surgery History and physical note

LP72701-3 History and physical note 68711-1 Pain medicine History and physical note

LP72701-3 History and physical note 68721-0 Pediatric cardiology History and physical note

LP72701-3 History and physical note 68731-9 Pediatric dermatology History and physical note

LP72701-3 History and physical note 68735-0 Pediatric endocrinology History and physical note

LP72701-3 History and physical note 68740-0 Pediatric gastroenterology History and physical note

LP72701-3 History and physical note 68751-7 Pediatric hematology-oncology History and physical note

LP72701-3 History and physical note 68760-8 Pediatric infectious diseases History and physical note

LP72701-3 History and physical note 68770-7 Pediatric nephrology History and physical note

LP72701-3 History and physical note 68775-6 Pediatric otolaryngology History and physical note

LP72701-3 History and physical note 68781-4 Pediatric pulmonology History and physical note

LP72701-3 History and physical note 68791-3 Pediatric rheumatology History and physical note

LP72701-3 History and physical note 68797-0 Pediatric surgery History and physical note

LP72701-3 History and physical note 68858-0 Pediatric transplant hepatology History and physical note

LP72701-3 History and physical note 68807-7 Pediatric urology History and physical note

LP72701-3 History and physical note 68817-6 Pediatrics History and physical note

LP72701-3 History and physical note 68825-9 Pediatrics Hospital History and physical note

LP72701-3 History and physical note 28626-0 Physician History and physical note

LP72701-3 History and physical note 34116-4 Physician Nursing facility History and physical note

LP72701-3 History and physical note 68592-5 Plastic surgery History and physical note

LP72701-3 History and physical note 68833-3 Primary care History and physical note

LP72701-3 History and physical note 11492-6 Provider-unspecifed, History and physical note

LP72701-3 History and physical note 68599-0 Psychiatry History and physical note

LP72701-3 History and physical note 68843-2 Speech-language pathology History and physical note

LP72701-3 History and physical note 34774-0 Surgery History and physical note

LP72701-3 History and physical note 68849-9 Transplant surgery History and physical note


LP72753-4 Hospital discharge instructions 8653-8 Hospital discharge instructions [Text] Narrative

LP74106-3 Hysterectomy consent 52028-8 Hysterectomy consent

LP72798-9 Informed consent obtained 19826-7 Informed consent obtained

LP57352-4 Initial evaluation note 64065-6 Case manager Hospital Initial assessment note

LP57352-4 Initial evaluation note 28581-7 Chiropractor Initial assessment note

LP57352-4 Initial evaluation note 28572-6 Dentist Initial assessment note

LP57352-4 Initial evaluation note 68553-7 Hematology and oncology Initial assessment note

LP57352-4 Initial evaluation note 34118-0 Home health Initial assessment note

LP57352-4 Initial evaluation note 47044-3 Hospital Initial assessment note

LP57352-4 Initial evaluation note 29753-1 Nurse Initial assessment note

LP57352-4 Initial evaluation note 28621-1 Nurse practitioner Initial assessment note

LP57352-4 Initial evaluation note 34119-8 Nursing facility Initial assessment note

LP57352-4 Initial evaluation note 18734-4 Occupational therapy Initial assessment note

LP57352-4 Initial evaluation note 34120-6 Outpatient Initial assessment note

LP57352-4 Initial evaluation note 18735-1 Physical therapy Initial assessment note

LP57352-4 Initial evaluation note 28654-2 Physician attending Initial assessment note

LP57352-4 Initial evaluation note 18763-3 Physician consulting Initial assessment note

LP57352-4 Initial evaluation note 18736-9 Physician Initial assessment note

LP57352-4 Initial evaluation note 18737-7 Podiatry Initial assessment note

LP57352-4 Initial evaluation note 28636-9 Provider-unspecified Initial assessment

LP57352-4 Initial evaluation note 28635-1 Psychiatry Initial assessment note

LP57352-4 Initial evaluation note 18738-5 Psychology Initial assessment note

LP57352-4 Initial evaluation note 68470-4 Respiratory therapy Hospital Initial assessment note

LP57352-4 Initial evaluation note 18739-3 Social service Initial assessment note

LP57352-4 Initial evaluation note 18740-1 Speech-language pathology Initial assessment note

LP72824-3 Interventional procedure note 34896-1 Cardiovascular disease Interventional procedure note

LP72824-3 Interventional procedure note 34899-5 Gastroenterology Interventional procedure note

LP72824-3 Interventional procedure note 34121-4 Interventional procedure note

LP96926-8 Labor and delivery admission history and physical note 57056-4 Labor and delivery admission history and physical note

LP96927-6 Labor and delivery summary note 57057-2 Labor and delivery summary note

LP116198-5 Legal document 64299-1 Legal document

LP74130-3 Letter 68620-4 Adolescent medicine Hospital Letter

LP74130-3 Letter 68624-6 Advanced heart failure and transplant cardiology Hospital Letter

LP74130-3 Letter 68634-5 Allergy and immunology Hospital Letter

LP74130-3 Letter 68649-3 Child and adolescent psychiatry Hospital Letter

LP74130-3 Letter 68662-6 Clinical genetics Hospital Letter

LP74130-3 Letter 68671-7 Developmental-behavioral pediatrics Hospital Letter

LP74130-3 Letter 68555-2 Hematology and oncology Hospital Letter

LP74130-3 Letter 68609-7 Hospital Letter


LP74130-3 Letter 51852-2 Letter

LP74130-3 Letter 68682-4 Multi-specialty program Hospital Letter

LP74130-3 Letter 68686-5 Neonatal perinatal medicine Hospital Letter

LP74130-3 Letter 68684-0 Neonatal perinatal medicine Letter

LP74130-3 Letter 68695-6 Neurological surgery Hospital Letter

LP74130-3 Letter 68707-9 Neurology w special qualifications in child neuro Hospital Letter

LP74130-3 Letter 68567-7 Obstetrics and Gynecology Hospital Letter

LP74130-3 Letter 68571-9 Occupational therapy Hospital Letter

LP74130-3 Letter 68576-8 Ophthalmology Hospital Letter

LP74130-3 Letter 68585-9 Orthopedic surgery Hospital Letter

LP74130-3 Letter 68717-8 Pain medicine Hospital Letter

LP74130-3 Letter 68728-5 Pediatric cardiology Hospital Letter

LP74130-3 Letter 68893-7 Pediatric dermatology Hospital Letter

LP74130-3 Letter 68898-6 Pediatric endocrinology Hospital Letter

LP74130-3 Letter 68747-5 Pediatric gastroenterology Hospital Letter

LP74130-3 Letter 68758-2 Pediatric hematology-oncology Hospital Letter

LP74130-3 Letter 68766-5 Pediatric infectious diseases Hospital Letter

LP74130-3 Letter 68870-5 Pediatric nephrology Hospital Letter

LP74130-3 Letter 68866-3 Pediatric nephrology Letter

LP74130-3 Letter 68875-4 Pediatric otolaryngology Hospital Letter

LP74130-3 Letter 68789-7 Pediatric pulmonology Hospital Letter

LP74130-3 Letter 68880-4 Pediatric rheumatology Hospital Letter

LP74130-3 Letter 68803-6 Pediatric surgery Hospital Letter

LP74130-3 Letter 68865-5 Pediatric transplant hepatology Hospital Letter

LP74130-3 Letter 68813-5 Pediatric urology Hospital Letter

LP74130-3 Letter 68826-7 Pediatrics Hospital Letter

LP74130-3 Letter 68598-2 Plastic surgery Hospital Letter

LP74130-3 Letter 68593-3 Plastic surgery Letter

LP74130-3 Letter 68838-2 Primary care Hospital Letter

LP74130-3 Letter 68847-3 Speech-language pathology Hospital Letter

LP74130-3 Letter 68853-1 Transplant surgery Hospital Letter

LP96928-4 Maternal discharge summary note 57058-0 Maternal discharge summary note

LP134149-6 Medication management note 70006-2 Medication management note

LP134149-6 Medication management note 68587-5 Pharmacy Hospital Medication management note

LP72988-6 Note 68615-4 Adolescent medicine Note

LP72988-6 Note 68621-2 Advanced heart failure and transplant cardiology Note

LP72988-6 Note 68629-5 Allergy and immunology Note

LP72988-6 Note 34750-0 Anesthesiology Note

LP72988-6 Note 68636-0 Audiology Note

LP72988-6 Note 34752-6 Cardiovascular disease Note


LP72988-6 Note 34753-4 Cardiovascular disease Outpatient Note

LP72988-6 Note 46210-1 Case manager Note

LP72988-6 Note 68645-1 Child and adolescent psychiatry Note

LP72988-6 Note 68650-1 Clinical biochemical genetics Note

LP72988-6 Note 68656-8 Clinical genetics Note

LP72988-6 Note 34754-2 Critical Care Medicine Note

LP72988-6 Note 64069-8 Critical care medicine.physician attending Hospital Note

LP72988-6 Note 28618-7 Dentistry Note

LP72988-6 Note 34772-4 Deprecated General surgery Note

LP72988-6 Note 68561-0 Deprecated Obstetrics and Gynecology Note

LP72988-6 Note 68842-4 Deprecated Speech pathology Note

LP72988-6 Note 34759-1 Dermatology Note

LP72988-6 Note 68666-7 Developmental-behavioral pediatrics Note

LP72988-6 Note 34861-5 Diabetology Note

LP72988-6 Note 34110-7 Diabetology Outpatient Note

LP72988-6 Note 34111-5 Emergency department Note

LP72988-6 Note 34878-9 Emergency medicine Note

LP72988-6 Note 34898-7 Endocrinology Note

LP72988-6 Note 34762-5 Gastroenterology Note

LP72988-6 Note 34765-8 General medicine Note

LP72988-6 Note 34766-6 General medicine Outpatient Note

LP72988-6 Note 34767-4 General medicine.medical student Note

LP72988-6 Note 34768-2 General medicine.nurse Note

LP72988-6 Note 34769-0 General medicine.physician attending Note

LP72988-6 Note 68672-5 Geriatric medicine Skilled nursing facility Note

LP72988-6 Note 34780-7 Hematology and oncology Note

LP72988-6 Note 34112-3 Hospital Note

LP72988-6 Note 34782-3 Infectious disease Note

LP72988-6 Note 34794-8 Interdisciplinary Note

LP72988-6 Note 34784-9 Kinesiotherapy Note

LP72988-6 Note 34786-4 Mental health Note

LP72988-6 Note 68677-4 Multi-specialty program Note

LP72988-6 Note 34796-3 Nephrology Note

LP72988-6 Note 34799-7 Neurological surgery Note

LP72988-6 Note 34905-0 Neurology Note

LP72988-6 Note 68700-4 Neurology w special qualifications in child neuro Note

LP72988-6 Note 34109-9 Note

LP72988-6 Note 57053-1 Nurse Emergency department Note

LP72988-6 Note 34746-8 Nurse Note

LP72988-6 Note 34139-6 Nurse Telephone encounter Note

LP72988-6 Note 34113-1 Nursing facility Note


LP72988-6 Note 34801-1 Nutrition and dietetics Note

LP72988-6 Note 34778-1 Obstetrics and Gynecology Note

LP72988-6 Note 34802-9 Occupational health Note

LP72988-6 Note 28578-3 Occupational therapy Note

LP72988-6 Note 34806-0 Oncology Note

LP72988-6 Note 34808-6 Ophthalmology Note

LP72988-6 Note 34811-0 Optometry Note

LP72988-6 Note 34813-6 Oromaxillofacial surgery Note

LP72988-6 Note 68888-7 Orthopedic surgery Note

LP72988-6 Note 34815-1 Orthopedics Note

LP72988-6 Note 34817-7 Otorhinolaryngology Note

LP72988-6 Note 34108-1 Outpatient Note

LP72988-6 Note 34858-1 Pain management Note

LP72988-6 Note 68712-9 Pain medicine Note

LP72988-6 Note 34906-8 Pastoral care Note

LP72988-6 Note 34819-3 Pathology Evaluation and management note

LP72988-6 Note 51855-5 Patient Note

LP72988-6 Note 68722-8 Pediatric cardiology Note

LP72988-6 Note 68889-5 Pediatric dermatology Note

LP72988-6 Note 68894-5 Pediatric endocrinology Note

LP72988-6 Note 68741-8 Pediatric gastroenterology Note

LP72988-6 Note 68752-5 Pediatric hematology-oncology Note

LP72988-6 Note 68761-6 Pediatric infectious diseases Note

LP72988-6 Note 68867-1 Pediatric nephrology Note

LP72988-6 Note 68871-3 Pediatric otolaryngology Note

LP72988-6 Note 68782-2 Pediatric pulmonology Note

LP72988-6 Note 68854-9 Pediatric rehabilitation medicine Note

LP72988-6 Note 68876-2 Pediatric rheumatology Note

LP72988-6 Note 68881-2 Pediatric surgery Note

LP72988-6 Note 68859-8 Pediatric transplant hepatology Note

LP72988-6 Note 68882-0 Pediatric urology Note

LP72988-6 Note 68827-5 Pediatrics Hospital Note

LP72988-6 Note 68818-4 Pediatrics Note

LP72988-6 Note 34821-9 Pharmacy Note

LP72988-6 Note 34823-5 Physical medicine and rehabilitation Note

LP72988-6 Note 28579-1 Physical therapy Note

LP72988-6 Note 28568-4 Physician Emergency department Note

LP72988-6 Note 34827-6 Plastic surgery Note

LP72988-6 Note 34829-2 Podiatry Note

LP72988-6 Note 68834-1 Primary care Note

LP72988-6 Note 28628-6 Psychiatry Note


LP72988-6 Note 68601-4 Psychiatry Outpatient Note

LP72988-6 Note 34792-2 Psychology Note

LP72988-6 Note 64077-1 Pulmonary disease.physician attending Hospital Note

LP72988-6 Note 34830-0 Pulmonary Note

LP72988-6 Note 34832-6 Radiation oncology Note

LP72988-6 Note 34834-2 Recreational therapy Note

LP72988-6 Note 34836-7 Rehabilitation Note

LP72988-6 Note 68839-0 Research Note

LP72988-6 Note 34838-3 Respiratory therapy Note

LP72988-6 Note 34840-9 Rheumatology Note

LP72988-6 Note 28653-4 Social work Note

LP72988-6 Note 34844-1 Social work Telephone encounter Note

LP72988-6 Note 28571-8 Speech-language pathology Note

LP72988-6 Note 34846-6 Speech-language pathology+Audiology Note

LP72988-6 Note 34857-3 Substance abuse Note

LP72988-6 Note 34848-2 Surgery Note

LP72988-6 Note 34773-2 Surgery.physician attending Note

LP72988-6 Note 34748-4 Telephone encounter Note

LP72988-6 Note 34850-8 Thoracic surgery Outpatient Note

LP72988-6 Note 64073-0 Thoracic surgery.physician attending Hospital Note

LP72988-6 Note 68848-1 Transplant surgery Note

LP72988-6 Note 34852-4 Urology Note

LP72988-6 Note 34854-0 Vascular surgery Outpatient Note

LP72988-6 Note 46215-0 Wound care management Note

LP116226-4 Organ donation consent 64300-7 Organ donation consent

LP64625-4 Pathology procedure note 34122-2 Pathology procedure note

LP157909-5 Plan of care note 64295-9 Nurse Plan of care note

LP157909-5 Plan of care note 56447-6 Plan of care note

LP73134-6 Post-operative evaluation and management note 34863-1

Deprecated General surgery Post-operative evaluation and management note


Hospital Post-operative evaluation and management note


Ophthalmology Outpatient Post-operative evaluation and management note


Ophthalmology Post-operative evaluation and management note

LP73134-6 Post-operative evaluation and management note 67860-7 Post-operative evaluation and management note


Surgery Hospital Post-operative evaluation and management note


Surgery Post-operative evaluation and management note



Surgery.nurse Post-operative evaluation and management note

LP116225-6 Power of attorney 64298-3 Power of attorney

LP96929-2 Pregnancy visit summary note 57059-8 Pregnancy visit summary note

LP73142-9 Pre-operative evaluation and management note 68616-2

Adolescent medicine Pre-operative evaluation and management note


Advanced heart failure and transplant cardiology Pre-operative evaluation and management note


Anesthesiology Hospital Pre-operative evaluation and management note


Anesthesiology Pre-operative evaluation and management note


Audiology Pre-operative evaluation and management note


Clinical genetics Pre-operative evaluation and management note


Deprecated General surgery Pre-operative evaluation and management note


Dermatology Pre-operative evaluation and management note


Multi-specialty program Pre-operative evaluation and management note


Neurological surgery Pre-operative evaluation and management note


Neurology w special qualifications in child neuro Pre-operative evaluation and management note

LP73142-9 Pre-operative evaluation and management note 34747-6 Nurse Pre-operative evaluation and management note


Obstetrics and Gynecology Pre-operative evaluation and management note


Ophthalmology Pre-operative evaluation and management note


Orthopedic surgery Pre-operative evaluation and management note


Pain medicine Pre-operative evaluation and management note


Pediatric cardiology Pre-operative evaluation and management note


Pediatric dermatology Pre-operative evaluation and management note


Pediatric endocrinology Pre-operative evaluation and management note


Pediatric gastroenterology Pre-operative evaluation and management note


Pediatric hematology-oncology Pre-operative evaluation and management note



Pediatric infectious diseases Pre-operative evaluation and management note


Pediatric nephrology Pre-operative evaluation and management note


Pediatric otolaryngology Pre-operative evaluation and management note


Pediatric pulmonology Pre-operative evaluation and management note


Pediatric rheumatology Pre-operative evaluation and management note


Pediatric surgery Pre-operative evaluation and management note


Pediatric transplant hepatology Pre-operative evaluation and management note


Pediatric urology Pre-operative evaluation and management note


Pediatrics Hospital Pre-operative evaluation and management note


Pediatrics Pre-operative evaluation and management note


Plastic surgery Pre-operative evaluation and management note

LP73142-9 Pre-operative evaluation and management note 67862-3 Pre-operative evaluation and management note


Primary care Pre-operative evaluation and management note


Speech-language pathology Pre-operative evaluation and management note

LP73142-9 Pre-operative evaluation and management note 34876-3 Surgery Pre-operative evaluation and management note


Surgery.nurse Pre-operative evaluation and management note


Transplant surgery Pre-operative evaluation and management note

LP116222-3 Procedure consent 64293-4 Procedure consent

LP134153-8 Progress letter 68607-1 Progress letter

LP74253-3 Progress note 68617-0 Adolescent medicine Progress note

LP74253-3 Progress note 68631-1 Allergy and immunology Progress note

LP74253-3 Progress note 68472-0 Cardiovascular disease Hospital Progress note

LP74253-3 Progress note 34124-8 Cardiovascular disease Outpatient Progress note

LP74253-3 Progress note 68485-2 Cardiovascular disease.medical student Hospital Progress note

LP74253-3 Progress note 68484-5 Cardiovascular disease.physician attending Hospital Progress note

LP74253-3 Progress note 34125-5 Case manager Home health care Progress note

LP74253-3 Progress note 68646-9 Child and adolescent psychiatry Progress note


LP74253-3 Progress note 28580-9 Chiropractor Progress note

LP74253-3 Progress note 68659-2 Clinical genetics Progress note

LP74253-3 Progress note 64059-9 Critical Care Medicine Hospital Progress note

LP74253-3 Progress note 64071-4 Critical care medicine.medical student Hospital Progress note

LP74253-3 Progress note 68473-8 Critical care medicine.physician attending Hospital Progress note

LP74253-3 Progress note 34128-9 Dentistry Outpatient Progress note

LP74253-3 Progress note 28617-9 Dentistry Progress note

LP74253-3 Progress note 34127-1 Dentistry.hygienist Outpatient Progress note

LP74253-3 Progress note 68845-7 Deprecated Speech pathology Progress note

LP74253-3 Progress note 68668-3 Developmental-behavioral pediatrics Progress note

LP74253-3 Progress note 34901-9 General medicine Outpatient Progress note

LP74253-3 Progress note 34900-1 General medicine Progress note

LP74253-3 Progress note 64055-7 General medicine.medical student Hospital Progress note

LP74253-3 Progress note 68475-3 General medicine.physician attending Hospital Progress note

LP74253-3 Progress note 68554-5 Hematology and oncology Progress note

LP74253-3 Progress note 34129-7 Home health Progress note

LP74253-3 Progress note 34130-5 Hospital Progress note

LP74253-3 Progress note 34126-3 Intensive care unit Progress note

LP74253-3 Progress note 72556-4 Interventional radiology Progress note

LP74253-3 Progress note 34904-3 Mental health Progress note

LP74253-3 Progress note 68679-0 Multi-specialty program Progress note

LP74253-3 Progress note 68693-1 Neurological surgery Progress note

LP74253-3 Progress note 68703-8 Neurology w special qualifications in child neuro Progress note

LP74253-3 Progress note 28575-9 Nurse practitioner Progress note

LP74253-3 Progress note 28623-7 Nurse Progress note

LP74253-3 Progress note 68564-4 Obstetrics and Gynecology Progress note

LP74253-3 Progress note 11507-1 Occupational therapy Progress note

LP74253-3 Progress note 68574-3 Ophthalmology Progress note

LP74253-3 Progress note 68582-6 Orthopedic surgery Progress note

LP74253-3 Progress note 34131-3 Outpatient Progress note

LP74253-3 Progress note 68725-1 Pediatric cardiology Progress note

LP74253-3 Progress note 68891-1 Pediatric dermatology Progress note

LP74253-3 Progress note 68896-0 Pediatric endocrinology Progress note

LP74253-3 Progress note 68744-2 Pediatric gastroenterology Progress note

LP74253-3 Progress note 68755-8 Pediatric hematology-oncology Progress note

LP74253-3 Progress note 68763-2 Pediatric infectious diseases Progress note

LP74253-3 Progress note 68873-9 Pediatric otolaryngology Progress note


LP74253-3 Progress note 68785-5 Pediatric pulmonology Progress note

LP74253-3 Progress note 68878-8 Pediatric rheumatology Progress note

LP74253-3 Progress note 68800-2 Pediatric surgery Progress note

LP74253-3 Progress note 68862-2 Pediatric transplant hepatology Progress note

LP74253-3 Progress note 68810-1 Pediatric urology Progress note

LP74253-3 Progress note 68830-9 Pediatrics Hospital Progress note

LP74253-3 Progress note 34132-1 Pharmacy Outpatient Progress note

LP74253-3 Progress note 11508-9 Physical therapy Progress note

LP74253-3 Progress note 18733-6 Physician attending Progress note

LP74253-3 Progress note 28569-2 Physician consulting Progress note

LP74253-3 Progress note 68595-8 Plastic surgery Progress note

LP74253-3 Progress note 11509-7 Podiatry Progress note

LP74253-3 Progress note 15507-7 Provider-unspecified ED Progress note

LP74253-3 Progress note 11506-3 Provider-unspecified Progress note

LP74253-3 Progress note 28627-8 Psychiatry Progress note

LP74253-3 Progress note 11510-5 Psychology Progress note

LP74253-3 Progress note 64063-1 Pulmonary disease Hospital Progress note

LP74253-3 Progress note 64079-7 Pulmonary disease.medical student Hospital Progress note

LP74253-3 Progress note 68478-7 Pulmonary disease.physician attending Hospital Progress note

LP74253-3 Progress note 68840-8 Research Progress note

LP74253-3 Progress note 68479-5 Respiratory therapy Hospital Progress note

LP74253-3 Progress note 28656-7 Social service Progress note

LP74253-3 Progress note 11512-1 Speech-language pathology Progress note

LP74253-3 Progress note 64057-3 Surgery Hospital Progress note

LP74253-3 Progress note 64067-2 Surgery.medical student Hospital Progress note

LP74253-3 Progress note 68480-3 Surgery.physician attending Hospital Progress note

LP74253-3 Progress note 64061-5 Thoracic surgery Hospital Progress note

LP74253-3 Progress note 64075-5 Thoracic surgery.medical student Hospital Progress note

LP74253-3 Progress note 68481-1 Thoracic surgery.physician attending Hospital Progress note

LP74253-3 Progress note 70238-1 Transplant surgery Hospital Progress note

LP97117-3 Referral note 57170-3 Cardiovascular disease Referral note

LP97117-3 Referral note 57178-6 Critical Care Medicine Referral note

LP97117-3 Referral note 57134-9 Dentistry Referral note

LP97117-3 Referral note 57140-6 Deprecated General surgery Referral note

LP97117-3 Referral note 57135-6 Dermatology Referral note

LP97117-3 Referral note 57136-4 Diabetology Referral note

LP97117-3 Referral note 57137-2 Endocrinology Referral note

LP97117-3 Referral note 69438-0 Forensic medicine Referral note

LP97117-3 Referral note 57138-0 Gastroenterology Referral note


LP97117-3 Referral note 57139-8 General medicine Referral note

LP97117-3 Referral note 57171-1 Geriatric medicine Referral note

LP97117-3 Referral note 57172-9 Hematology and oncology Referral note

LP97117-3 Referral note 57141-4 Infectious disease Referral note

LP97117-3 Referral note 57142-2 Kinesiotherapy Referral note

LP97117-3 Referral note 57143-0 Mental health Referral note

LP97117-3 Referral note 57144-8 Nephrology Referral note

LP97117-3 Referral note 57146-3 Neurological surgery Referral note

LP97117-3 Referral note 57145-5 Neurology Referral note

LP97117-3 Referral note 57173-7 Nutrition and dietetics Referral note

LP97117-3 Referral note 57179-4 Obstetrics and Gynecology Referral note

LP97117-3 Referral note 57147-1 Occupational health Referral note

LP97117-3 Referral note 57148-9 Occupational therapy Referral note

LP97117-3 Referral note 57149-7 Oncology Referral note

LP97117-3 Referral note 57150-5 Ophthalmology Referral note

LP97117-3 Referral note 57151-3 Optometry Referral note

LP97117-3 Referral note 57174-5 Oral surgery Referral note

LP97117-3 Referral note 57175-2 Orthopedic surgery Referral note

LP97117-3 Referral note 57176-0 Otolaryngology Referral note

LP97117-3 Referral note 57152-1 Pharmacy Referral note

LP97117-3 Referral note 57153-9 Physical medicine and rehabilitation Referral note

LP97117-3 Referral note 57154-7 Physical therapy Referral note

LP97117-3 Referral note 57155-4 Plastic surgery Referral note

LP97117-3 Referral note 57156-2 Podiatry Referral note

LP97117-3 Referral note 57157-0 Psychiatry Referral note

LP97117-3 Referral note 57158-8 Psychology Referral note

LP97117-3 Referral note 57177-8 Pulmonary disease Referral note

LP97117-3 Referral note 57159-6 Radiation oncology Referral note

LP97117-3 Referral note 57160-4 Recreational therapy Referral note

LP97117-3 Referral note 57133-1 Referral note

LP97117-3 Referral note 57161-2 Rehabilitation Referral note

LP97117-3 Referral note 57162-0 Respiratory therapy Referral note

LP97117-3 Referral note 57163-8 Rheumatology Referral note

LP97117-3 Referral note 57164-6 Social work Referral note

LP97117-3 Referral note 57165-3 Speech-language pathology Referral note

LP97117-3 Referral note 57166-1 Surgery Referral note

LP97117-3 Referral note 57167-9 Thoracic surgery Referral note

LP97117-3 Referral note 57168-7 Urology Referral note

LP97117-3 Referral note 57169-5 Vascular surgery Referral note

LP116221-5 Release of information consent 64292-6 Release of information consent

LP135445-7 Restraint note 68476-1 Nurse Hospital Restraint note


LP135445-7 Restraint note 68474-6 Physician Hospital Restraint note

LP135445-7 Restraint note 70007-0 Restraint note

LP74339-0 Sterilization consent 52029-6 Sterilization consent

LP133905-2 Summarization note 68603-0 Radiation oncology Hospital Summarization note

LP133905-2 Summarization note 68602-2 Radiation oncology Summarization note

LP133905-2 Summarization note 68608-9 Summarization note

LP73427-4 Summarization of episode note 34133-9 Summarization of episode note

LP73428-2 Summary note 51900-9 Summary note

LP73428-2 Summary note 61143-4 Summary note Nursing

LP57353-2 Summary of death note 47046-8 Summary of death note

LP73429-0 Summary purpose 48764-5 Summary purpose CCD Document

LP57354-0 Supervisory note 34135-4 Cardiovascular disease.physician attending Outpatient Supervisory note

LP57354-0 Supervisory note 34136-2 Gastroenterology.physician attending Outpatient Supervisory note

LP57354-0 Supervisory note 67865-6 Outpatient Supervisory note

LP57354-0 Supervisory note 34134-7 Physician attending Outpatient Supervisory note

LP57354-0 Supervisory note 47047-6 Supervisory note

LP102489-4 Surgical operation consent 61358-8 Surgical operation consent Document Patient

LP73465-4 Surgical operation note 28583-3 Dentist Operation note

LP73465-4 Surgical operation note 34868-0 Orthopedics Surgical operation note

LP73465-4 Surgical operation note 34818-5 Otorhinolaryngology Surgical operation note

LP73465-4 Surgical operation note 34137-0 Outpatient Surgical operation note

LP73465-4 Surgical operation note 28573-4 Physician, Operation note

LP73465-4 Surgical operation note 34870-6 Plastic surgery Surgical operation note

LP73465-4 Surgical operation note 28624-5 Podiatry Operation note

LP73465-4 Surgical operation note 11504-8 Provider-unspecified Operation note

LP73465-4 Surgical operation note 34874-8 Surgery Surgical operation note

LP73465-4 Surgical operation note 34877-1 Urology Surgical operation note

LP73490-2 Targeted history and physical note 34138-8 Targeted history and physical note

LP73545-3 Transfer of care referral note 34140-4 Transfer of care referral note

LP73546-1 Transfer summarization note 68618-8 Adolescent medicine Transfer summarization note

LP73546-1 Transfer summarization note 68632-9 Allergy and immunology Transfer summarization note

LP73546-1 Transfer summarization note 68647-7 Child and adolescent psychiatry Transfer summarization note

LP73546-1 Transfer summarization note 68660-0 Clinical genetics Transfer summarization note

LP73546-1 Transfer summarization note 34755-9 Critical Care Medicine Transfer summarization note

LP73546-1 Transfer summarization note 68669-1 Developmental-behavioral pediatrics Transfer summarization note

LP73546-1 Transfer summarization note 34770-8 General medicine Transfer summarization note

LP73546-1 Transfer summarization note 68680-8 Multi-specialty program Transfer summarization note


LP73546-1 Transfer summarization note 68704-6 Neurology w special qualifications in child neuro Transfer summarization note

LP73546-1 Transfer summarization note 68482-9 Nurse Hospital Transfer summarization note

LP73546-1 Transfer summarization note 28651-8 Nurse Transfer note

LP73546-1 Transfer summarization note 68565-1 Obstetrics and Gynecology Transfer summarization note

LP73546-1 Transfer summarization note 68569-3 Occupational therapy Transfer summarization note

LP73546-1 Transfer summarization note 68887-9 Ophthalmology Transfer summarization note

LP73546-1 Transfer summarization note 68583-4 Orthopedic surgery Transfer summarization note

LP73546-1 Transfer summarization note 68715-2 Pain medicine Transfer summarization note

LP73546-1 Transfer summarization note 68726-9 Pediatric cardiology Transfer summarization note

LP73546-1 Transfer summarization note 68737-6 Pediatric endocrinology Transfer summarization note

LP73546-1 Transfer summarization note 68745-9 Pediatric gastroenterology Transfer summarization note

LP73546-1 Transfer summarization note 68756-6 Pediatric hematology-oncology Transfer summarization note

LP73546-1 Transfer summarization note 68764-0 Pediatric infectious diseases Transfer summarization note

LP73546-1 Transfer summarization note 68772-3 Pediatric nephrology Transfer summarization note

LP73546-1 Transfer summarization note 68777-2 Pediatric otolaryngology Transfer summarization note

LP73546-1 Transfer summarization note 68786-3 Pediatric pulmonology Transfer summarization note

LP73546-1 Transfer summarization note 68793-9 Pediatric rheumatology Transfer summarization note

LP73546-1 Transfer summarization note 68801-0 Pediatric surgery Transfer summarization note

LP73546-1 Transfer summarization note 68863-0 Pediatric transplant hepatology Transfer summarization note

LP73546-1 Transfer summarization note 68811-9 Pediatric urology Transfer summarization note

LP73546-1 Transfer summarization note 68884-6 Pediatrics Hospital Transfer summarization note

LP73546-1 Transfer summarization note 68883-8 Pediatrics Transfer summarization note

LP73546-1 Transfer summarization note 28616-1 Physician Transfer note

LP73546-1 Transfer summarization note 68596-6 Plastic surgery Transfer summarization note

LP73546-1 Transfer summarization note 18761-7 Provider-unspecified Transfer summary

LP76330-7 Triage note 54094-8 Emergency department Triage note

LP96924-3 Triage+care note 57054-9 Nurse Emergency department Triage+care note

LP73592-5 VA C&P exam.acromegaly note 38932-0

VA Compensation and Pension (C and P) examination acromegaly

LP73593-3

VA C&P exam.aid and attendance &or housebound note 38933-8

VA Compensation and Pension (C and P) examination aid and attendance/housebound

LP73594-1 VA C&P exam.arrhythmias note 38934-6

VA Compensation and Pension (C and P) examination arrhythmias

LP73595-8 VA C&P exam.audio note 38936-1 VA Compensation and Pension (C and P) examination audio

LP73596-6 VA C&P exam.bones fractures &or bone disease note 38937-9

VA Compensation and Pension (C and P) examination bones fractures/bone disease

LP73597-4 VA C&P exam.brain &or spinal cord note 38938-7

VA Compensation and Pension (C and P) examination brain/spinal cord


LP73598-2 VA C&P exam.chronic fatigue syndrome note 38939-5

VA Compensation and Pension (C and P) examination chronic fatigue syndrome

LP73599-0 VA C&P exam.cold injury protocol note 38940-3

VA Compensation and Pension (C and P) examination cold injury protocol

LP73600-6 VA C&P exam.cranial nerves note 38941-1

VA Compensation and Pension (C and P) examination cranial nerves

LP73601-4 VA C&P exam.Cushings syndrome note 38942-9

VA Compensation and Pension (C and P) examination Cushings syndrome

LP73602-2 VA C&P exam.dental &or oral note 38943-7

VA Compensation and Pension (C and P) examination dental/oral

LP73603-0 VA C&P exam.diabetes mellitus note 38944-5

VA Compensation and Pension (C and P) examination diabetes mellitus

LP73604-8 VA C&P exam.disability in gulf war veterans note 38956-9

VA Compensation and Pension (C and P) examination disability in gulf war veterans

LP73605-5 VA C&P exam.ear disease note 38946-0 VA Compensation and Pension (C and P) examination ear disease

LP73606-3 VA C&P exam.epilepsy &or narcolepsy note 38949-4

VA Compensation and Pension (C and P) examination epilepsy/narcolepsy

LP73607-1 VA C&P exam.esophagus &or hiatal hernia note 38950-2

VA Compensation and Pension (C and P) examination esophagus/hiatal hernia

LP73608-9 VA C&P exam.extremity joints note 38966-8

VA Compensation and Pension (C and P) examination extremity joints

LP73609-7 VA C&P exam.eye note 38951-0 VA Compensation and Pension (C and P) examination eye

LP73610-5 VA C&P exam.feet note 38952-8 VA Compensation and Pension (C and P) examination feet

LP73611-3 VA C&P exam.fibromyalgia note 38953-6

VA Compensation and Pension (C and P) examination fibromyalgia

LP73612-1 VA C&P exam.general medical note 38954-4

VA Compensation and Pension (C and P) examination general medical

LP73613-9 VA C&P exam.general mental disorders note 38969-2

VA Compensation and Pension (C and P) examination general mental disorders

LP73614-7 VA C&P exam.genitourinary note 38955-1

VA Compensation and Pension (C and P) examination genitourinary

LP73615-4

VA C&P exam.gynecological conditions &or disorders of the breast note 38957-7

VA Compensation and Pension (C and P) examination gynecological conditions/disorders of the breast

LP73616-2 VA C&P exam.hand &or thumb &or fingers note 38958-5

VA Compensation and Pension (C and P) examination hand/thumb/fingers

LP73617-0 VA C&P exam.heart note 38959-3 VA Compensation and Pension (C and P) examination heart

LP73618-8 VA C&P exam.hemic disorders note 38960-1

VA Compensation and Pension (C and P) examination hemic disorders

LP73619-6 VA C&P exam.HIV-related illness note 38961-9

VA Compensation and Pension (C and P) examination HIV-related illness

LP73620-4 VA C&P exam.hypertension note 38962-7

VA Compensation and Pension (C and P) examination hypertension


LP73621-2

VA C&P exam.infectious &or immune &or nutritional disabilities note 38963-5

VA Compensation and Pension (C and P) examination infectious/immune/nutritional disabilities

LP73622-0

VA C&P exam.initial evaluation post-traumatic stress disorder note 38964-3

VA Compensation and Pension (C and P) examination initial evaluation post-traumatic stress disorder

LP73623-8 VA C&P exam.large &or small intestines note 38965-0

VA Compensation and Pension (C and P) examination large/small intestines

LP73624-6 VA C&P exam.liver &or gall bladder &or pancreas note 38967-6

VA Compensation and Pension (C and P) examination liver/gall bladder/pancreas

LP73625-3 VA C&P exam.lymphatic disorders note 38968-4

VA Compensation and Pension (C and P) examination lymphatic disorders

LP73626-1 VA C&P exam.mental health eating disorders note 38947-8

VA Compensation and Pension (C and P) examination mental health eating disorders

LP73627-9 VA C&P exam.miscellaneous arteries &or veins note 38935-3

VA Compensation and Pension (C and P) examination miscellaneous arteries/veins

LP73628-7 VA C&P exam.miscellaneous digestive conditions note 38945-2

VA Compensation and Pension (C and P) examination miscellaneous digestive conditions

LP73629-5 VA C&P exam.miscellaneous endocrine diseases note 38948-6

VA Compensation and Pension (C and P) examination miscellaneous endocrine diseases

LP73630-3 VA C&P exam.miscellaneous neurological disorders note 38972-6

VA Compensation and Pension (C and P) examination miscellaneous neurological disorders

LP73631-1 VA C&P exam.miscellaneous respiratory diseases note 38980-9

VA Compensation and Pension (C and P) examination miscellaneous respiratory diseases

LP73632-9 VA C&P exam.mouth &or lips &or tongue note 38970-0

VA Compensation and Pension (C and P) examination mouth/lips/tongue

LP73633-7 VA C&P exam.muscles note 38971-8 VA Compensation and Pension (C and P) examination muscles

LP73634-5 VA C&P exam.nose &or sinus &or larynx &or pharynx note 38973-4

VA Compensation and Pension (C and P) examination nose/sinus/larynx/pharynx

LP73635-2

VA C&P exam.obstructive &or restrictive &or interstitial respiratory diseases note 38979-1

VA Compensation and Pension (C and P) examination obstructive/restrictive/interstitial respiratory diseases

LP73636-0 VA C&P exam.peripheral nerves note 38974-2

VA Compensation and Pension (C and P) examination peripheral nerves

LP73637-8 VA C&P exam.prisoner of war protocol note 38975-9

VA Compensation and Pension (C and P) examination prisoner of war protocol

LP73638-6

VA C&P exam.pulmonary tuberculosis &or mycobacterial diseases note 38976-7

VA Compensation and Pension (C and P) examination pulmonary tuberculosis/mycobacterial diseases

LP73639-4 VA C&P exam.rectum &or anus note 38977-5

VA Compensation and Pension (C and P) examination rectum/anus

LP73640-2 VA C&P exam.residuals of amputations note 38978-3

VA Compensation and Pension (C and P) examination residuals of amputations

LP73641-0

VA C&P exam.review evaluation post-traumatic stress disorder note 38981-7

VA Compensation and Pension (C and P) examination review evaluation post-traumatic stress disorder


LP73642-8 VA C&P exam.scars note 38982-5 VA Compensation and Pension (C and P) examination scars

LP73643-6 VA C&P exam.sense of smell &or taste note 38983-3

VA Compensation and Pension (C and P) examination sense of smell/taste

LP73644-4 VA C&P exam.skin diseases other than scars note 38984-1

VA Compensation and Pension (C and P) examination skin diseases other than scars

LP73645-1 VA C&P exam.social &or industrial survey note 38985-8

VA Compensation and Pension (C and P) examination social/industrial survey

LP73646-9 VA C&P exam.spine note 38986-6 VA Compensation and Pension (C and P) examination spine

LP73647-7

VA C&P exam.stomach &or duodenum &or peritoneal adhesions note 38987-4

VA Compensation and Pension (C and P) examination stomach/duodenum/peritoneal adhesions

LP73648-5 VA C&P exam.thyroid &or parathyroid diseases note 38988-2

VA Compensation and Pension (C and P) examination thyroid/parathyroid diseases

LP100067-0 Well child visit note 59283-2 Well child visit note

Table 5 – Proposed LOINC Clinical Document Types


4 I MP LE MEN TA T IO N OF TH E ONT O LO GY

The LOINC Clinical Document Ontology is an existing ontology that is developed and

maintained by Regenstrief. This section of the implementation guide goes beyond the current structure of the Clinical Document Ontology and specifically speaks to the

proposed implementation characteristics for use of the ontology.

This section forms the core of the purpose for implementation of an ontology of clinical

documents – mainly, that with the ontology already defined and maintained through

Regenstrief, the core pupose for implementation is to increase standardized adoption of LOINC clinical document types as a way to enhance semantic interoperability.

4.1 Implementation Basics

To establish use of the LOINC Clinical Document Ontology in settings beyond that

specified for current usage, it is necessary to establish implementation guidance for its

usage, which is the basis for this document. This section establishes a framework for

implementation by presenting various implementation options for the ontology using

existing HL7, IHE, and other interoperability standards.

This implementation framework is expected to undergo extensive review by clinicians

and implementers as it passes through balloting, and will then be maintained as an

ongoing implementation guide to serve as the normative standard for usage of LOINC


The operating basis for implementation is to NOT change the current ontology within

the implementation guide, so scope of implementation is specific to the current

ontology, and the use of supporting standards to enhance its value.

4.2 Summary of Conformance Statements

Conformance is not a specific focus of the implementation guide, as this guide exists

primarily as a framework for use. Thus, no specific conformance statements for

implementation are established through this guide. Instead, similar to the approach

adopted by HITSP, the clinical document types within the ontology serve as a source for

further constraint and extension of acceptable values.

An example of conformance from HITSP would be how the document type value set was

defined. The value set was specified as a dynamic value set that is tied to the LOINC

clinical document ontology and then is tied to implementation (in this case an XDS

Affinity Domain).

The Registry Stored Query and Retrieve Document Set transactions within the IHE XD*

stack then specifically constrain to a set of coded values needed to represent clinical

document types. As IHE is a profile, the level of constraint and conformance is specific

to the implementer.

4.3 Using the Ontology


In the proposed approach for the LOINC Document Ontology, there are multiple use

cases that will be developed to support the implementation of the ontology. These use

cases for implementation are outlined in Section 5 of this implementation guide. These use cases were developed to support the notion of initial conceptual implementation of

the ontology for the purposes of future piloting efforts.

The most basic use case is the searching of a specific clinical document type based on

the current LOINC Clinical Document Ontology based on the current version of LOINC

esablished and maintained

Additional use cases would expand upon this base use case to support broader search

parameters and to allow for retrieval by LOINC Part Number, for example, where the

registry supports use of only Type of Setting, for example, and the Component axe as

the search parameter.

To use the ontology, an implementer would create LOINC codes for all required

combinations as documented by DOD and VA for the iEHR. This approach would NOT

document all possible combinations of codes, but only those codes that are required for

iEHR implementation

As a proposed national standard, the LOINC Document Ontology would then be

designed to support these required combinations. Additional possible combinations

could be supported through either of the following processes:

1. Submission to HL7 and LOINC for recognition as a required combination

2. Implementation within the local organization’s ontology by extending the base

ontology to support additional possible combinations

A more advanced use case is searching for specific clinical document types based on

more complex pairings of axes

Each name within the ontology would be ordered as follows:

<Subject Matter Domain> : <Training / Professional Level>: <Setting>: <Type> :

Note *

4.3.1 Example of LOINC Ontology Usage

A Disability Claims Adjudicator within the VBA received a claim for disability for debilitating back pain. The disability determination requires a history of illness in order

to process the claim and ensure against fraud and abuse. The adjudicator needs to

have a predictable way to query for related documents in order to gather the

information needed to make a determination.

Specific to the LOINC Ontology, the Adjudicator performed a query request using a

LOINC document code. This proves problematic since many documents would be

returned, increasing determination time. An example of this quandary would be a

search of the following LOINC code:

History of Past Illness - 11349-8

Several issues exist when related to disability of service members and the need to

search for documents associated with a disability:


DoD performs disability evaluations of injured/ill service members as part of the

Medical Evaluation Boards.

VA performs disability evaluations of injured/ill former service members as part

of Compensation and Pension.

SSA requires disability evaluations of injured/ill former service members as part

of Social Security Disability insurance.

There are additional challenges in this example:

Additional properties will not fit into the existing LOINC table

LOINC defining axis is used inconsistently

LOINC defining axis is overloaded.

4.3.2 Use of Metadata for implementation

An important building block in this implementation guide is expression of metadata

with the clinical document type. This is the main purpose of the implementation guide – define implementation using existing standards and show how specific metadata can be

applied to LOINC clinical document types to further enhance query and retrieval

capabilities.

4.3.2.1 Expected Metadata Attributes

For each clinical document type, additional metadata attributes can be associated with

the clinical document type, including the following attributes:

Author of the clinical document

Location of the service performed

Date of the service performed

Status of the clinical document

Use of security and privacy metadata

There would be no specific standardization proposed for these metadata elements

within this implementation guide. Instead, the framework proposed is to provide

different examples of how this metadata could be applied with clinical document types

(such as part of the metadata associated with a XD* transaction) that an actor such as

a Document Consumer could locate and review.

4.4 Reuse of Existing Taxonomies

There are several existing taxonomies that are also defined by other organizations as

prospective terminologies to reference and align the LOINC Document Ontology to. Each

of these taxonomies is proposed within this implementation guide as possible

taxonomies to use in the population of metadata surrounding a clinical document type.

4.4.1 LOINC A key source for the current implementation guide is the past work of the HL7/LOINC

Document Ontology Task Force. This task force developed much of the current clinical


document ontology that is now in use within LOINC and would be relied on as a

primary source of expert review and consultation for the current implementation guide

proposed for the LOINC Clinical Document Ontology.

As noted throughout this implementation guide, Regenstrief (and LOINC) serve as the

primary owners for the LOINC Clinical Document Ontology and revisions and changes

to its content and structure are managed through Regenstrief-specific processes.

4.4.2 HL7

The LOINC Document Ontology would have potential overlap with those values provided

in support of HL7 2.x messaging. The HL7 document type code domain will overlap with

similar concepts found in HL7 V2.x (user defined table 0270 Document Types; user

defined table 0496 Consent Types).

The proposed approach for reuse is to provide a mapping from LOINC codes proposed in

this ontology to HL7 V2.x document codes as a future appendix within this

implementation guide. It is also recognized that the HL7 V3 domain may contain

concepts that are not present in the V2.x tables and will also require a future mapping

to be developed as an appendix to this implementation guide.

This use of terminologies is consistent with text as defined in the LOINC Users Guide:

HL7 will use LOINC codes for clinical document codes, and will not develop an independent document code system for clinical documents. At its option, HL7 may choose to limit its domain to a subset of LOINC codes. HL7 can incorporate any LOINC document code into the HL7 domain.

4.4.2.1 HL7 Consent Vocabularies

Because of the increasingly sensitive nature of patient data a consideration for

including supporting metadata to manage sensitive document types is also proposed

within this implementation guide.

The proposed LOINC Document Ontology would seek to incorporate HL7 vocabularies

that support definition of specialized document types that have the potential of

containing highly sensitive information. The use of consent vocabularies would be

accomplished through including additional support for metadata that is associated with


4.4.3 ABMS

ABMS helps to define the specific medical specialties that would be used to populate the Role axe for a specific LOINC code associated with a clinical document type. The

primary role of ABMS (American Board of Medical Specialties) is to leverage the current

list of Approved ABMS Specialty Boards & Certificates as part of defining the Role value

within the LOINC Clinical Document Ontology.

Usage of ABMS vocabularies would be subject to specific approval by ABMS and by Regenstrief.


4.4.4 NUCC The provider types defined by NUCC for a healthcare provider taxonomy (commonly

referred to as Healthcare Provider Type Taxonomy) serve as another source for

populating the Method and System axes that are needed to define a clinical document

type.

The proposed approach for reuse is to ensure a mapping is available from the provider

types listed within the NUCC Healthcare Provider Type taxonomy to the following axes:

Type of Setting – as defined in the System axe

Role – as defined in the Method axe

4.4.5 SNOMED-CT

One of the challenges in using LOINC to build a document ontology is that other

terminologies have characteristics which would support their usage as potential code

systems for implementing an ontology of this type. An example of this challenge is

SNOMED-CT, which can also be used as a document type identifier.

The proposed reuse of SNOMED-CT for the LOINC Document Ontology is to support

development of a supporting clinical document map (LOINC to SNOMED-CT) which

would be available to support the identification of LOINC document type codes by using

a SNOMED-CT code. This is envisioned as a longer term goal as the implementation

guide for the LOINC Clinical Document Ontology moves closer to normative status.

4.5 Implementation Approaches for Document Type

Representation

In addition to methods of implementation for the querying of a clinical document type,

representation of the ontology is also critical for implementation. This implementation

guide does not define a single method of representation but supports multiple proposals

whereby each of the document types defined in this guide can be expressed using one

or more representational formats, that can be shared and used in multiple

environments.

4.5.1 XML Representation The most common representation that is used for clinical document types is as part of

an XML representation. For example, CDA represents clinical document types using XML, as shown in the example below:

<code codeSystem="2.16.840.1.113883.6.1"

codeSystemName="LOINC"

code="34133-9"

displayName="Summarization of Episode Note"/>

<title>Community Health and Hospitals: Health Summary</title>


4.5.2 RDF Representation An alternative representation that may also work within the context of implementation

for a LOINC clinical document type is use of RDF. This would be especially relevant for

implementations such as those associated with FHIR, where a Document or

DocumentReference resource can be expressed in different formats, including RDF

4.5.3 JSON Representation Similar to possible usage of RDF as a format, the use of JSON to represent document

types is also supported. This supports the use of XPath queries for the specific JSON

element representing the type. The following example highlights how this approach would work:

"type": { "text": {"value": "Discharge Summarization Note"},

"coding": [{

"system": {"value": "www.loinc.org"},

"code": {"value": "28655-9"}

}]

},

4.6 Implementation Approaches to Queries

The initial scope of this implementation guide is not to specifically define an

implementation approach that would be required to be implemented at a national level

but to lay out various options for implementation that would be used for piloting and

implementation. This includes the area of queries and the use of a standardized and

structured document type to represent the data

Support existing implementation using a standard metadata registry provided

within the implementation environment

Support existing implementations using an XDS document repository

Support existing implementations using a RESTful API to access a FHIR

resource

4.6.1 Use of Existing Metadata Registries Using a metadata registry that already exists within an existing health information

exchange (HIE) or other implementation environment is another approach supported for

implementation of the LOINC Clinical Document Ontology. The DOD/VA use case is

predicated on the idea of implementation the LOINC Clinical Document Ontology within

a metadata registry and as the primary source of clinical document types within an

internal implementation

An example of this approach is using a metadata registry that would support the

querying of metadata to search for a locally mapped set of document codes (such as a

bundle of unstructured documentation or a set of LOINC clinical document types as

defined in the LOINC Clinical Document Ontology that map to several local LOINC document codes)

The proposed implementation approach for use of existing metadata registries would

also support the mapping of metadata included in a local registry to the attributes of


the LOINC Clinical Document Ontology. The LOINC Document Ontology would have no

major changes needed to support this approach. The implementation would rely on the

local implementation to ensure that conformance to the Clinical Document Ontology was enforced.

4.6.2 Use of XD* Metadata To support the necessary query and search functions that use of a LOINC Document

Ontology would support, coordination with IHE as a representative standards body

would be needed. The main methods for using XDS to search for LOINC would be the

use of XD* metadata to search for a specified LOINC code that represents the clinical

document type that is being queried for.

The proposed approach in this implementation guide would be to map XD* metadata to

the existing fields that would needed from the LOINC clinical document type to support

this implementation approach.

typeCode Machine computable LOINC code that represents the

LOINC clinical document type from this implementation guide

classCode Tied to typeCode

eventCode Aligned to LOINC Clinical Document Ontology.Time

practiceSettingCode Aligned to LOINC Clinical Document Ontology.Type of

Setting

authorSpecialty Aligned to LOINC Clinical Document Ontology.SMD

authorRole Aligned to LOINC Clinical Document Ontology.Role

specialtyCode Aligned to LOINC Clinical Document Ontology.SMD

formatCode Aligned to LOINC Clinical Document Ontology.Scale

value where value=‖DOC‖

mimeTypeCode Specific to the metadata registry being used, the

mimeTypeCode

Table 6 – Mapping LOINC Clinical Document Ontology to IHE XD* Metadata

4.6.3 Use of FHIR and REST

The Clinical Document Ontology would also support enviornments where implementation of document types as a bundle of FHIR resources may be desirable.

For example, in the DOD/VA approach, specific clinical documents would be defined

using the Fast Healthcare Interoperability Resource, or FHIR, specification.

The document codes as defined in the LOINC Document Ontology would be used as the

formal resource identifiers for each of these resources, to expedite identification of FHIR resources and resource bundles to better support interoperability.

The proposed approach to using FHIR to query for document types could have multiple

options, and each can be leveraged to include additional metadata with the clinical

document type to include information such as privacy and security metadata, provenance metadata, etc…

4.6.3.1 Use of Clinical Document Type with FHIR Document resource


In this implementation approach, the FHIR document resource would be used to

represent the metadata for the clinical document type

The example below shows the base definition of th

4.6.3.2 Use of Clinical Document Type with FHIR DocumentReference resource

Similar to the approach used for Document resource, the clinical document type is also expressed using the <type> element, as shown in the example below:

<type> <coding>

<system value="http://loinc.org"/>

<code value="34108-1"/>

<display value="Outpatient Evaluation And Management"/>

</coding>

</type>

This is specifically used for situations where non-FHIR specific resources are specified

with a clinical document type.

4.6.3.3 Use of Clinical Document Type with FHIR resource bundle

In this implementation approach, the ResourceReference field can be populated using

the LOINC clinica ldocument type to show the different clinical document types

expressed in the bundle.

Implementation details on this approach are ongoing.

4.6.3.4 Use of Clinical Document Type with hData implementation

In this approach, the implementation of the clinical document type would occur within

the root document of the hData hierarchy.

Implementation details on this approach are ongoing.


5 PR OP OSE D U SE CA SES F OR IM P LE MEN TAT IO N

To support development and design of the LOINC Clinical Document Ontology (CDO) as a potential standard to be balloted within an implementation guide, a series of use

cases are outlined below, that represent POSSIBLE uses of the LOINC Clinical

Document Ontology within the context of an implementation.

These use cases are summarized below:

5.1 Query using RESTful API

5.2 Query Examples using IHE XD*

5.2.1 Querying within the Domain of Implementation

5.2.1.1 Using XD* to Query for Domain

5.2.2 Querying using the Document Type

5.2.2.1 Using XD* to Query for Document Type

5.2.3 Querying using the Role

5.2.3.1 Using XD* to Query for Role

5.2.4 Querying using the Care Setting In the query for the care setting, the specific data element that is used is the Type of

Setting as the

5.2.4.1 Using XD* to Query for Care Setting

5.2.5 Querying using the Type of Service Provided

5.2.5.1 Using XD* to Query for Type of Service

5.3 Querying Remote Registries or Repositories

In this scenario, implementation would be focused on supporting queries to remote

registries of information, such as a Document Registry or Metadata Registry which

contains patient and/or administrative information

1. Requests documents by LOINC code


2. Receives list of possible matches

3. Receiver has documents which fit multiple document codes-->creates copy of

document with each code that document fulfills

5.4 Vocabulary Considerations for SNOMED-CT

5.4.1 Populate value sets for individual dimensions

Value sets are mapped to SNOMED-CT and other usual and customary terminology

systems to facilitate interoperability, deployment, query, completeness, and reuse.

5.4.2 Generate full (combinatorial) ontology

5.4.3 Map legacy LOINC codes into new ontology

5.5 Long Term Implementation Considerations

The proposed implementation approach within this implementation guide would begin

by reusing the existing components of LOINC and its LOINC Clinical Document Ontology. The intent of this implementation guide approach is to establish an initial

document taxonomy using the current structure of LOINC. Expansion of the LOINC

terminology to support additional attributes is not precluded by this implementation

guide.


6 VA LUE SE T MAPP IN G T O ONTO LO GY

While the document types themselves all have codes in LOINC, the value sets

corresponding to the dimensions of the ontology do not.

The expected intention for this implementation guide is to both:

1. Clearly identify the value set that corresponds with each of the axes within the

ontology

2. Map all values in those value sets to corresponding SNOMED CT codes

To support the implementation guide value set mapping to the LOINC Clinical

Document Ontology, this implementation guide will reference the work already

performed as part of HITSP C80.

ValueSet OID ValueSet Name Binding


7 R EF EREN CE S

Several references, both formal and informal, were used to create this implementation

guide. Each of these references were used in support of development and the usage of the specific reference is also detailed below.

Name of Reference Proposed Usage in this Implementation

Guide

LOINC Clinical Document Ontology The primary source for the values

populated in this implementation guide is

the LOINC Clinical Document Ontology

and its representation within RELMA

HITSP C80 HITSP C80 and specifically the Document

Type value set defined in HITSP C80 are

used as references to support specification

of the referenced clinical document types

LOINC® Document Ontology Proposed

Extension and Revision

Coonan, 2011

This white paper and supporting slide

deck were used as part of research for the

implementation guide and to provide additional material for support of certain

sections in the implementation guide.

Document Ontology Proposed Changes for

Harmonization This spreadsheet documented specific

harmonization proposals that were

included in the initial version of the LOINC

Clinical Document Ontology. This spreadsheet was referenced to ensure no

duplication of existing work efforts. Logical Observation Identifiers Names and

Codes (LOINC) Users' Guide

Chapter 7 is the primary reference

resource for defining and maintaining the

document ontology

Huff SM, chair. Document Ontology Task

Force. Proposal for an Ontology for

Exchange of Clinical Documents. [monograph on the Internet] Ann Arbor:

Health Level Seven, Inc. c1997–2005

The initial proposal for the LOINC Clinical

Document Ontology was used as a major

source for initial information on how to structure the implementation guide and

define potential uses for implementation

Huff SM, Rocha RA, McDonald CJ, et al.

Development of the Logical Observations

Identifiers, Names, and Codes (LOINC)

vocabulary. J Am Med Inform Assoc. 1998;5:276–92

Additional research sources for the

implementation guide

Huff SM, Frazier P, Dolin RH. HL7 LOINC

Document Type Vocabulary Domain

Paper. [monograph on the Internet]

Indianapolis: Regenstrief Institute, Inc.

c2004

Additional research sources for the

implementation guide


APPEN DIX A — A CR ONYM S AND ABB REV I AT I ONS

ABMS American Board of Medical Specialties

AMA American Medical Association

CCD Continuity of Care Document

CDA Clinical Document Architecture

CDC Centers for Disease Control and

Prevention

DAM Domain Analysis Model

DICOM Digital Imaging and Communications in

Medicine

EHR Electronic Health Record

DSTU Draft Standard for Trial Use

H&P History and Physical

HIT healthcare information technology

HITECH Health Information Technology for

Economic and Clinical Health

HITSP Health Information Technology Standards

Panel

HL7 Health Level Seven

HHS U.S. Department of Health and Human

Services

HTML Hypertext Markup Language

IG Implementation Guide

IHE Integrating the Healthcare Enterprise

IHTSDO International Health Terminology

Standard Development Organisation

LOINC Logical Observation Identifiers Names and

Codes

MIME Multipurpose Internet Mail Extensions

NUCC Healthcare Provider Taxonomy Code

ONC Office of National Coordinator

PCP Primary Care Provider

PDF Portable Document Format


RELMA Regenstrief LOINC Mapping Assistant

RIM Reference Information Model

SDWG Structured Documents Working Group

SDO Standards Development Organization

SNOMED CT Systemized Nomenclature for Medicine –

Clinical Terms

UCUM Unified Code for Units of Measure

UML Unified Modeling Language

URL Uniform Resource Locator

XPath XML Path Language


APPEN DIX B — C HANG E H I S TO RY ON ON TOLO GY

To be populated as part of ballot reconciliation

New and Updated Clinical Document Types will be populated in this appendix as the

implementation guide follows the HL7 balloting process. This will allow for tracking of any proposed changes

Clinical Document Type Short Name LOINC ID

New clinical document types

Updated clinical document types

Page 121 HL7/LOINC Clinical Document Ontology Implementation Guide © 2012 Health Level Seven, Inc. All rights reserved. July 2012

APPEN DIX C - C ON F OR MANC E VER BS

The next table represents a matrix of the conformance verbs used across the standards

reviewed for the consolidation guide. Cells with a dash (-) did not have an equivalent conformance convention.

This table is drawn from the HL7 Consolidated CDA Conformance Verb matrix.

RFC 2119 HL7 IHE HITSP Workgroup Consensus

SHALL

Absolute

requirement of the

specification

SHALL

Required/Mandatory

R (Required)

Element must be

present but can be

NULL

R (Required)

Data elements

must always be

sent. A NULL can

be sent.

SHALL

Element must be

present but can be

NULL

Where necessary to

explicitly preclude

nullFlavor (e.g. where

you want to preclude

nullFlavor on

observation/value), can

include something like

"SHALL NOT include

nullFlavor".

Where SHALL is

applied to an attribute,

it must be present and

cannot be a NULL

SHALL NOT

Absolute

prohibition of the

specification

SHALL NOT

Not

Required/Mandatory

- - SHALL NOT

Absolute prohibition

against inclusion


RFC 2119 HL7 IHE HITSP Workgroup Consensus

SHOULD

Recommended

There may exist

valid reasons in

particular

circumstances to

ignore a particular

item, but the full

implications must

be understood and

carefully weighed

before choosing a

different course.

SHOULD

Best Practice or

Recommendation

R2 (Required if

known)

The sending

application must

be able to

demonstrate that it

can send all

required if known

elements, unless it

does not in fact

gather that data. If

the information

cannot be

transmitted, the

data element shall

contain a value

indicating the

reason for

omission of the

data.

R2 (Required if

known)

If the sending

application has

data for the data

element, it is

REQUIRED to

populate the

data element. If

the value is not

known, the data

element need not

be sent

SHOULD

Best Practice or

Recommendation

There may exist valid

reasons in particular

circumstances to

ignore a particular

item, but the full

implications must be

understood and

carefully weighed

before choosing a

different course

SHOULD NOT

Not Recommended

SHOULD NOT

Not Recommended

- - SHOULD NOT

Not Recommended

MAY

Optional

MAY

Accepted/Permitted

O (Optional) O (Optional) MAY

Optional

- - C (Conditional)

A conditional data

element is one that

is required,

required if known

or optional

depending upon

other conditions.

C (Conditional)

Required to be

sent when the

conditions

specified in the

HITSP additional

specifications

column are true

-


APPEN DIX D - EX TEN S I ONS TO LOIN C D O CU MEN T O NT O LOGY

If a specific representation of a document type cannot be found within the LOINC

Document Ontology, extensions to the ontology will be supported. These extensions will

be developed . This section serves to summarize the process for submitting extensions

and implementation guidance on how to do so.

Extensions created for this guide would follow several rules that would be subject to

HL7 and LOINC review

Proposed extensions should not replicate existing document types to provide

new metadata

To resolve issues that need to be addressed by extension of an ontology, the developers

of this guide chose to approach extensions as follows:

An extension should include element or attribute declarations and rules for the

specific document type proposed for addition

All extensions would initially be considered as optional. An extension may be

used, but need not be required for use as defined by this guide

The HL7 Structured Documents Working Group shall be the initial body charged

with reviewing extensions

This ontology shall be used as the primary source for any extension elements or

attributes that are defined for new clinical document types

Each extension element shall use the same conventions for order and naming as

is used within this ontology