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
Vascular Access

Additional Names

Short Name
Vascular Access Prog note

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.77
Last Updated
Version 2.77
Order vs. Observation
Both

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38741-1 Progress note|ANYRole|ANYSetting
LG51622-5 Vascular Access|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
it-IT Italian (Italy) Progresso, nota:Osservazione:Pt:{Setting}:Doc:Accesso vascolare
Synonyms: Documentazione dell''ontologia Nota di progresso;Nota di miglioramento Osservazione Punto nel tempo (episodio)

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=104122-7