Version 2.82

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

LOINC Names Get Info

Fully-Specified Name
Progress note:Find:Pt:{Setting}:Doc:Social worker
Long Common Name
Social worker Progress note
Short Name
SW Prog note

Part Model Get Info

  • Component
    Progress note
    LP74253-3
    • Analyte
      Progress note
      LP74253-3
      • Component Numerator
        Progress note
        LP74253-3
        • Component Numerator Core
          Progress note
          LP74253-3
        • Component Numerator Core Suffix
          NULL
           
      • Component Denominator
        NULL
         
        • Component Denominator Core
          NULL
           
        • Component Denominator Core Suffix
          NULL
           
    • Challenge
      NULL
       
    • Adjustment
      NULL
       
    • Count
      NULL
       
  • Property
    Find
    LP6813-2
  • Time
    Pt
    LP6960-1
    • Time Core
      Pt
      LP6960-1
    • Time Modifier
      NULL
       
  • System
    {Setting}
    LP32887-9
    • System Core
      {Setting}
      LP32887-9
    • Super System
      NULL
       
  • Scale
    Doc
    LP32888-7
  • Method
    Social worker
    LP269800-1

Associated Observations

81216-4 Progress note - recommended C-CDA R2.0 and R2.1 sections

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 note 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 note O

72225-6 Progress note - recommended C-CDA R1.1 sections

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 note O
Indent11450-4 Problem list - Reported O
Indent30954-2 Relevant diagnostic tests/laboratory data note O
Indent10187-3 Review of systems Narrative - Reported O
Indent61150-9 Subjective Narrative O
Indent8716-3 Vital signs note O

81243-8 Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sections

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 note R
Indent77596-5 Transportation summary Document R
Indent42348-3 Advance healthcare 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 note 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 note R
Indent10164-2 History of Present illness Narrative R
Indent11369-6 History of Immunization note 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 note 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 note R
Indent10187-3 Review of systems Narrative - Reported R
Indent61150-9 Subjective Narrative R
Indent8716-3 Vital signs note R

Basic Attributes

Class
DOC.ONTOLOGY
Type
Clinical
First Released
Version 2.00
Last Updated
Version 2.73 (MIN)
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. Also 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.; Changed Method from "Social work" to "Social worker" based on the Clinical LOINC Committee decision (10/2018) to represent Social work/er as a Role value in the LOINC Document Ontology.
Order vs. Observation
Both
HL7® Attachment Structure
Implementation guide exists

Member of these Panels

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

Member of these Groups Get Info

LOINC Group Group Name
LG41826-5 {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain
LG38741-1 Progress note|ANYRole|ANYSetting
LG38995-3 Social worker|ANYTypeOfService|ANYKindOfNote|ANYSetting

Language Variants Get Info

Tag Language Translation
el-GR Greek (Greece) Σημείωμα πορείας:Εύρεση:Pt:{Ρυθμίσεις}:Doc:Κοινωνικός λειτουργός
Synonyms: {Ρυθμίσεις} Doc DOC.ONTOLOGY Pt Εργάτης Εύρεση Κοινωνικός λειτουργός Σημείωμα πορείας Σημείωση
es-AR Spanish (Argentina) SUBSEQUENT EVALUATION NOTE:hallazgo:punto en el tiempo:{contexto}:Documento:servicio social
es-MX Spanish (Mexico) Nota de progreso:Tipo:Punto temporal:{Configuración}:Documento:Social worker
it-IT Italian (Italy) Progresso, nota:Osservazione:Pt:{Setting}:Doc:Assistente sociale
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:社会工作者
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 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 社会工作者（社会服务工作人员、社会服务工作者、社会福利救济工作者）;社会服务工作人员;社会服务工作者;社会福利救济工作者 笔记;按语;注释;说明;票据;单据;证明书 雇员;劳工;工人

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

CodeSystem lookup
https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=28656-7