Version 2.78

Part Description

LP74253-3   Progress note
Progress Note documents a patient's clinical status during a hospitalization or outpatient visit; thus, it is associated with an encounter.


Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."

Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."

A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833e defines the requirements of a Medicare Progress Report. Source: HL7

Fully-Specified Name

Component
Progress note
Property
Find
Time
Pt
System
Outpatient
Scale
Doc
Method
Social worker

Additional Names

Short Name
SW OP Prog note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.73
Last Updated
Version 2.73
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG41828-1 Outpatient|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38741-1 Progress note|ANYRole|ANYSetting
LG38995-3 Social worker|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Progresso, nota:Osservazione:Pt:Paziente esterno:Doc:Assistente sociale
Synonyms: Documentazione dell''ontologia Nota di progresso;Nota di miglioramento Osservazione Paziente ambulatoriale;Paziente non ricoverato Punto nel tempo (episodio)
zh-CN Chinese (China) 病程记录:发现:时间点:门诊病人:文档型:社会工作者
Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 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 文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体 时刻;随机;随意;瞬间 病程（进展、病程进展、病情进展、进展情况、变化情况、发展情况）记录;病程进展记录;病情进展记录 社会工作者（社会服务工作人员、社会服务工作者、社会福利救济工作者）;社会服务工作人员;社会服务工作者;社会福利救济工作者 笔记;按语;注释;说明;票据;单据;证明书 门诊患者

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=100532-1