Version 2.78

Description

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 Part Properties

Part Display Name
Progress note
Part Type
Component (Describes the core component or analyte measured)
Created On
2008-11-10
Construct for LOINC Short Name
Prog note

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=LP74253-3

Language Variants Get Info

Tag Language Translation
ru-RU Russian (Russian Federation) Прогресс запись
Synonyms: Дневник наблюдения
nl-NL Dutch (Netherlands) voortgangsrapport
it-IT Italian (Italy) Progresso, nota
Synonyms: Nota di progresso;Nota di miglioramento
fr-BE French (Belgium) Note de progrès
zh-CN Chinese (China) 病程记录
Synonyms: 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