Progress Note

This profile represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare 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 1833(e) defines the requirements of a Medicare Progress Report.

resourceCompositionactiveView in C-CDA on FHIR IG
Profile Name
ProgressNote
Base Definition
Derivation
constraint

Differential Elements (87)

Constraints and modifications from the base definition

PathCardinalityType(s)Must SupportDetails
Composition----
Composition.type--Yes-
Composition.section----
Composition.section
Slice: assessment_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: allergies_and_intolerances_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*---
Composition.section.entry----
Composition.section.entry
Slice: allergies_and_intolerances_entry
-
Reference
Yes
Target: us-core-allergyintolerance
Composition.section
Slice: assessment_and_plan_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: assessment_and_plan_entry
-
Reference
Yes
Target: us-core-conditionObservationCommunication
Composition.section
Slice: chief_complaint_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: instructions_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: interventions_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: interventions_section
-
Reference
Yes
Target: ListRequestGroup
Composition.section
Slice: medications_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: medications_entry
-
Reference
Yes
Target: MedicationStatementus-core-medicationus-core-medicationrequest
Composition.section
Slice: nutrition_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry--Yes-
Composition.section.entry
Slice: nutrition_entry
-
Reference
Yes
Target: Observation
Composition.section
Slice: objective_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: physical_exam_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: physical_exam_entry
-
Reference
Yes
Target: Observation
Composition.section
Slice: plan_of_treatment_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: sliceEntry
-
Reference
-
Target: us-core-goalus-core-medicationrequestus-core-encounterCommunicationAppointmentCommunicationRequestDeviceRequestNutritionOrderTaskServiceRequestVisionPrescriptionRequestGroup
Composition.section
Slice: problems_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: problem_entry
-
Reference
Yes
Target: us-core-condition
Composition.section
Slice: results_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry--Yes-
Composition.section.entry
Slice: results_entry
-
Reference
Yes
Target: us-core-observation-lab
Composition.section
Slice: review_of_systems_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: subjective_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section
Slice: vital_signs_section
*..1-Yes-
Composition.section.title1..*-Yes-
Composition.section.code1..*-Yes-
Composition.section.text1..*-Yes-
Composition.section.entry----
Composition.section.entry
Slice: vital_signs_entry
-
Reference
Yes
Target: vitalsigns