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Anesthesia and surgery report

Vocabulary Users
#1

Hi !

In the case of the anesthesia procedure, there is a pre-anesthesia visit, which occurred several days before the procedure. During this visit, a report is written by the anesthesiologist.
When integrated in NOTE, is this report linked to Ancillary report ? Or is more appropriate to create a new anesthesia report or note ?

Another point, at the end of the operation, a summary is written in the Anesthesia Information Management System. Is it a Discharge summary or is it also appropriate to have a “surgery” summary concept ?

#2

Really not sure if I understand your questions here. Are you trying to find the appropriate concept_id in the vocabulary for the report mentioned? If that is the case, LOINC has hierarchy of reports. The top level concept is “LOINC Document Ontology - Type of Service and Kind of Document” (concept_id = 36209248). The next level includes Administrative note, Consultation note, Procedure note, Report, Note, and etc. And there are more levels of concepts after that. In the attached Excel file, I have listed all the concept_id and concept_name in this hierarchy. Hope that helps. LOINC Document Ontology.xlsx (164.3 KB)

#3

Hi !

Thanks for your answer.
Indeed, I found all I need for the anesthesia procedure (e.g. 21492753 Anesthesiology Checklist, 46236104 Anesthesiology Consult note, 36203677 Anesthesiology Recovery room Discharge summary, …).
I think these concepts may be used for the note_class_concept_id of the NOTE table.

For the note_type_concept_id (which have to belong to the ‘Note Type’ vocabulary), 44814637 Discharge summary and 44814638 Admission Note may be used ?

#4

Yes. Both can be used as note_type_concept_id.

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