Version 2.77

Term Description

This document is a concise clinical document that provides an electronic, pre-defined patient health data set applicable both for unexpected, as well as expected (planned), health care contact. This document may be either the product of a medical act or an automatic excerpt from national/regional EHRs.

A Patient Summary gives a healthcare provider the essential information needed for health care coordination and, in cases of an unexpected need or when the patient consults a provider other than his regular contact person (e.g. the general practitioner he/she is registered with), this document enables continuity of care.

Because it is meant to be a summary, this document might not include a detailed medical history, details on clinical conditions or a full list of all prescriptions and dispensed medicines.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Patient summary
Property
Find
Time
Pt
System
^Patient
Scale
Doc
Method

Additional Names

Short Name
Patient summary Doc

Basic Attributes

Class
DOC.EPSOS
Type
Clinical
First Released
Version 2.34
Last Updated
Version 2.34

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Patient Summary
de-DE German (Germany) Patientenkurzakte:Befund:Zeitpunkt:^Patient:Dokument:
es-MX Spanish (Mexico) Resumen del paciente:Tipo:Punto temporal:^ Paciente:Documento:
it-IT Italian (Italy) Profilo sanitario sintetico:Osservazione:Pt:^Paziente:Doc:
Synonyms: Documenti (epSOS) Smart Open Services for European Osservazione paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) patiënt samenvatting:bevinding:moment:^patiënt:document:
ru-RU Russian (Russian Federation) Пациент краткие сведения:Находка:ТчкВрм:^Пациент:Док:
Synonyms: Документ Точка во времени;Момент
zh-CN Chinese (China) 患者摘要:发现:时间点:^患者:文档型:
Synonyms: epSOS 文档;epSOS;Smart Open Services for European Patients;欧洲患者智能开放服务 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论 患者（病人、病患、病号）摘要（小结、概要、总结、梗概、概括、总汇） 时刻;随机;随意;瞬间

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=60591-5