LOINC
Version 2.66

11507-1Occupational therapy Progress noteActive

Component
Progress note
Property
Find
Time
Pt
System
{Setting}
Scale
Doc
Method
Occupational therapy

Additional Names

Short Name
OT Progress note

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

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 1.0j-a
Last Updated
Version 2.58
Change Reason
Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. lso changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.
Order vs. Observation
Both
HL7 Attachment Structure
Implementation guide exists

Associated Observations

This panel contains the recommended sections for progress notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Releases 2.0 & 2.1.

LOINC Name R/O/C Cardinality Example UCUM Units
81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent48765-2 Allergies O
Indent10154-3 Chief complaint Narrative - Reported O
Indent69730-0 Instructions O
Indent62387-6 Interventions Narrative O
Indent10160-0 History of Medication use Narrative O
Indent61144-2 Diet and nutrition Narrative O
Indent61149-1 Objective Narrative O
Indent29545-1 Physical findings Narrative O
Indent11450-4 Problem list - Reported O
Indent30954-2 Results O
Indent10187-3 Review of systems Narrative - Reported O
Indent61150-9 Subjective Narrative O
Indent8716-3 Vital signs O

Associated Observations

This panel contains the recommended sections for progress notes based on the HL7 Implementation Guide for CDA® Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) DSTU Release 1.1.

LOINC Name R/O/C Cardinality Example UCUM Units
72225-6 Progress note - recommended C-CDA R1.1 sections
Indent51847-2 Assessment+Plan R
Indent51848-0 Assessment R
Indent18776-5 Plan of care R
Indent48765-2 Allergies O
Indent10154-3 Chief complaint Narrative - Reported O
Indent69730-0 Instructions O
Indent62387-6 Interventions Narrative O
Indent10160-0 History of Medication use Narrative O
Indent61149-1 Objective Narrative O
Indent29545-1 Physical findings Narrative O
Indent11450-4 Problem list - Reported O
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative O
Indent10187-3 Review of systems Narrative - Reported O
Indent61150-9 Subjective Narrative O
Indent8716-3 Vital signs O

Associated Observations

This panel contains the recommended sections for an enhanced encounter note based on the HL7 Clinical Documents for Payers - Set 1, Releases 1.0 & 1.1 (US Realm).

LOINC Name R/O/C Cardinality Example UCUM Units
81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections
Indent77599-9 Additional documentation R
Indent77598-1 Externally defined clinical data elements Document R
Indent47420-5 Functional status assessment note R
Indent77597-3 Orders placed Document R
Indent18776-5 Plan of care note R
Indent29762-2 Social history Narrative R
Indent77596-5 Transportation summary Document R
Indent42348-3 Advance directives O
Indent48765-2 Allergies R
Indent51847-2 Evaluation + Plan note R
Indent51848-0 Evaluation note R
Indent46239-0 Chief complaint+Reason for visit Narrative R
Indent10154-3 Chief complaint Narrative - Reported R
Indent46240-8 History of Hospitalizations+Outpatient visits Narrative R
Indent10157-6 History of family member diseases Narrative R
Indent10210-3 Physical findings of General status Narrative R
Indent61146-7 Goals Narrative R
Indent75310-3 Health concerns Document R
Indent11383-7 Patient problem outcome Narrative R
Indent11348-0 History of Past illness Narrative R
Indent10164-2 History of Present illness Narrative R
Indent11369-6 History of Immunization Narrative R
Indent69730-0 Instructions R
Indent62387-6 Interventions Narrative R
Indent46264-8 History of medical device use R
Indent10160-0 History of Medication use Narrative R
Indent10190-7 Mental status Narrative R
Indent61144-2 Diet and nutrition Narrative R
Indent61149-1 Objective Narrative R
Indent48768-6 Payment sources Document R
Indent29545-1 Physical findings Narrative R
Indent11450-4 Problem list - Reported R
Indent47519-4 History of Procedures Document R
Indent42349-1 Reason for referral (narrative) R
Indent29299-5 Reason for visit Narrative R
Indent30954-2 Relevant diagnostic tests/laboratory data Narrative R
Indent10187-3 Review of systems Narrative - Reported R
Indent61150-9 Subjective Narrative R
Indent8716-3 Vital signs R

Member of these Panels

LOINC Long Common Name
26443-2 Clinical reports.non lab claims attachment

Member of these Groups

LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38947-4 Occupational therapy|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38741-1 Progress note|ANYRole|ANYSetting

Language Variants Get Info

zh-CNChinese (China)
病程记录:发现:时间点:{环境}:文档型:职业疗法
nl-NLDutch (Netherlands)
voortgangsrapport:bevinding:moment:{instelling}:document:bezigheidstherapie
fr-BEFrench (Belgium)
Note de progrès:Observation:Temps ponctuel:{réglages}:Document:Traitement occupationnel
it-ITItalian (Italy)
Progresso, nota:Osservazione:Pt:{Setting}:Doc:Terapia occupazionale
es-ARSpanish (Argentina)
SUBSEQUENT EVALUATION NOTE:hallazgo:punto en el tiempo:{contexto}:Documento:terapia ocupacional

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=11507-1