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
{Setting}
Scale
Doc
Method
Kinesiotherapy

Additional Names

Short Name
Kinesiotherapy Prog note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.75
Last Updated
Version 2.75

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38971-4 Kinesiotherapy|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38741-1 Progress note|ANYRole|ANYSetting

Language Variants Get Info

Tag Language Translation
fr-BE French (Belgium) Note de progrès:Observation:Temps ponctuel:{réglages}:Document:Kinésithérapie
it-IT Italian (Italy) Progresso, nota:Osservazione:Pt:{Setting}:Doc:Chinesiterapia
Synonyms: Documentazione dell''ontologia Nota di progresso;Nota di miglioramento Osservazione Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) voortgangsrapport:bevinding:moment:{instelling}:document:kinesiotherapie
zh-CN Chinese (China) 病程记录:发现:时间点:{环境}:文档型:运动疗法
Synonyms: Movement therapy;Therapeutic exercise;治疗性训练;治疗性运动;治疗性锻炼;运动性治疗;运动治疗 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书 事件发生的地方;场景;环境;背景 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

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=101895-1