Version 2.74

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
Heart failure

Additional Names

Short Name
Heart failure Prog note

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

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

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

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.65
Last Updated
Version 2.73
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Groups

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG50117-7 Heart failure|ANYTypeOfService|ANYKindOfNote|ANYSetting
LG38741-1 Progress note|ANYRole|ANYSetting

Language Variants

Tag Language Translation
it-IT Italian (Italy) Progresso, nota:Osservazione:Pt:{Setting}:Doc:Insufficienza cardiaca
Synonyms: Documentazione dell''ontologia Nota di progresso;Nota di miglioramento Osservazione Punto nel tempo (episodio)
zh-CN Chinese (China) 病程记录:发现:时间点:{环境}:文档型:心力衰竭
Synonyms: 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 心力衰竭(心竭、心脏衰竭、心衰竭、心功能衰竭);心竭;心脏衰竭;心衰竭;心功能衰竭 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
es-MX Spanish (Mexico) Nota de progreso:Tipo:Punto temporal:{Configuración}:Documento:Heart failure

LOINC Terminology Service (API) using HL7® FHIR®

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=90772-5