LOINC

LOINC (Logical Observation Identifiers Names and Codes) is the international standard for identifying lab tests, clinical observations, and documents. Medera codes both lab orders / results and validated BH instruments to LOINC for FHIR Observation interoperability.

Lab orders / results

Standard LOINC applies — lipid panel, CBC, basic metabolic, TSH, drug screen, etc. The Medical Coding Agent surfaces the most-likely LOINC for any laboratory mention in the note.

BH instrument LOINC codes

Validated BH instruments emit as LOINC-coded Observation resources so they round-trip cleanly through FHIR.

Instrument	LOINC	Notes
PHQ-9 total score	`44261-6`	Depression severity score
PHQ-9 item 9 (suicide)	`44262-4`	Item-level flag
GAD-7 total score	`70274-6`	Generalized anxiety severity
AUDIT-C total score	`75624-7`	Alcohol use screen
AUDIT total score	`75626-2`	Full AUDIT
C-SSRS — past month severity	`93374-8`	Suicide-ideation severity
C-SSRS — past month behavior	`93375-5`	Suicide-behavior severity
MDQ total score	`71354-5`	Mood Disorder Questionnaire
ASRS total score	`93446-4`	Adult ADHD self-report
PCL-5 total score	`89204-2`	PTSD Checklist DSM-5
Edinburgh PND total	`71354-x`	Postnatal depression

Emission

When /sessions or /transcripts runs an instrument inline, each completed instrument emits as a FHIR Observation:

{
  "resourceType": "Observation",
  "status": "final",
  "code": { "coding": [{ "system": "http://loinc.org", "code": "44261-6", "display": "Patient Health Questionnaire 9 item (PHQ-9) total score" }] },
  "valueQuantity": { "value": 14, "unit": "score" },
  "interpretation": [{ "coding": [{ "code": "MOD", "display": "Moderate" }] }],
  "derivedFrom": [{ "reference": "DocumentReference/doc_abc#span_412_489" }]
}

What’s next

SNOMED CT

Clinical terminology.

Coding systems

Feature matrix + pairings.

Encounter coding

Use cases.

Validated screeners

Screener Expert.

Overview

Code Systems

Lab orders / results

BH instrument LOINC codes

Emission

What’s next

SNOMED CT

Coding systems

Encounter coding

Validated screeners

​Lab orders / results

​BH instrument LOINC codes

​Emission

​What’s next

SNOMED CT

Coding systems

Encounter coding

Validated screeners

Lab orders / results

BH instrument LOINC codes

Emission

What’s next