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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

LOINC Names Get Info

Fully-Specified Name
Progress note:Find:Pt:Outpatient:Doc:Wound care management
Long Common Name
Wound Care Management Outpatient Progress Note
Short Name
Wound Care Management OP Prog Note

Part Model Get Info

  • Component
    Progress note
    LP74253-3
    • Analyte
      Progress note
      LP74253-3
      • Component Numerator
        Progress note
        LP74253-3
        • Component Numerator Core
          Progress note
          LP74253-3
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Find
    LP6813-2
  • Time
    Pt
    LP6960-1
  • System
    Outpatient
    LP32889-5
    • System Core
      Outpatient
      LP32889-5
    • Super System
      NULL
       
  • Scale
    Doc
    LP32888-7
  • Method
    Wound care management
    LP76083-2

Basic Attributes

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

Member of these Groups Get Info

LOINC GroupGroup Name
LG41828-1Outpatient|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38741-1Progress note|ANYRole|ANYSetting
LG39045-6Wound care management|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Σημείωμα πορείας:Εύρεση:Pt:Εξωτερικός ασθενής:Doc:Διαχείριση φροντίδας τραύματος
Synonyms: Doc DOC.ONTOLOGY Pt Διαχείριση φροντίδας τραύματος Εξωτερικός ασθενής Εύρεση Σημείωμα πορείας Σημείωση
it-ITItalian (Italy)Progresso, nota:Osservazione:Pt:Paziente esterno,Paziente ambulatoriale,Paziente non ricoverato:Doc:Ferita, gestione della cura
Synonyms: Documentazione dell''ontologia Gestione della cura della ferita Nota di miglioramento Nota di progresso Osservazione Punto nel tempo (episodio)
nl-NLDutch (Netherlands)voortgangsrapport:bevinding:moment:poliklinisch:document:wondzorg
Synonyms: poli
zh-CNChinese (China)病程记录:发现:时间点:门诊病人:文档型:伤口护理管理
Synonyms: CARE Survey;Continuity Assessment Record and Evaluation;连续性评估记录与评价;连续性评估档案与评价;CARE 调查;CARE 问卷调查 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 伤口（创伤、创口）护理（照护）管理;创伤护理管理;创口护理管理;伤口医疗护理管理;伤口照护管理 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 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=100545-3