ProgressNote

Progress Note

activeC-CDA on FHIR1.2.0resource76 key elements

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.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/ccda/StructureDefinition/Progress-Note
ID
Progress-Note
Type
Base Definition
US-Realm-Header
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
type
S
type
:assessment_section
S
Assessment Section
section.title
S1+
title
section.code
S1+
Assessments
section.text
S1+
This section contains only human readable content
:allergies_and_intolerances_section
S
Allergies and Intolerances Section
section.title
S1+
title
section.code
S1+
Allergies, adverse reactions, alerts
section.text
1+
text
:allergies_and_intolerances_entry
Reference
S
:assessment_and_plan_section
S
Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
section.title
S1+
title
section.code
S1+
Assessment and plan
section.text
S1+
text
:assessment_and_plan_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:chief_complaint_section
S
Chief Complaint Section
section.title
S1+
title
section.code
S1+
Chief complaint
section.text
S1+
This section contains only human readable content
:instructions_section
S
Instructions Section
section.title
S1+
title
section.code
S1+
Instructions
section.text
S1+
This section contains only human readable content
:interventions_section
S
Interventions Section
section.title
S1+
title
section.code
S1+
Interventions provided
section.text
S1+
text
:interventions_section
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:medications_section
S
Medications Section
section.title
S1+
title
section.code
S1+
History of medication use
section.text
S1+
text
:medications_entry
Reference
S
:nutrition_section
S
Nutrition Section
section.title
S1+
title
section.code
S1+
Diet and nutrition
section.text
S1+
text
section.entry
S
entry
:nutrition_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:objective_section
S
Objective Section
section.title
S1+
title
section.code
S1+
Objective
section.text
S1+
This section contains only human readable content
:physical_exam_section
S
Physical Exam Section
section.title
S1+
title
section.code
S1+
Physical findings
section.text
S1+
text
:physical_exam_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:plan_of_treatment_section
S
Plan of Treatment Section
section.title
S1+
title
section.code
S1+
Plan of Treatment
section.text
S1+
text
:problems_section
S
Problems Section
section.title
S1+
title
section.code
S1+
Problem list
section.text
S1+
text
:problem_entry
Reference
S
:results_section
S
Results Section
section.title
S1+
title
section.code
S1+
Relevant diagnostic tests and/or laboratory data
section.text
S1+
text
section.entry
S
entry
:results_entry
Reference
S
:review_of_systems_section
S
Review of Systems Section
section.title
S1+
title
section.code
S1+
Review of systems
section.text
S1+
This section contains only human readable content
:subjective_section
S
Subjective Section
section.title
S1+
title
section.code
S1+
Subjective
section.text
S1+
This section contains only human readable content
:vital_signs_section
S
Vital Signs Section
section.title
S1+
title
section.code
S1+
Vital signs
section.text
S1+
text
:vital_signs_entry
Reference
S
This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.