Package | hl7.fhir.us.ccda |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | http://hl7.org/fhir/us/ccda/https://build.fhir.org/ig/HL7/ccda-on-fhir/StructureDefinition-Progress-Note.html |
Url | http://hl7.org/fhir/us/ccda/StructureDefinition/Progress-Note |
Version | 1.2.0 |
Status | active |
Date | 2024-03-12T16:03:19+00:00 |
Name | ProgressNote |
Title | Progress Note |
Experimental | False |
Realm | us |
Authority | hl7 |
Description | 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. |
Type | Composition |
Kind | resource |
CapabilityStatement | |
CcdaOnFhirClient ![]() | CCDA on FHIR Client |
CcdaOnFhirServer ![]() | CCDA on FHIR Server |
StructureDefinition | |
US-Realm-Header ![]() | US Realm Header |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance ![]() | US Core AllergyIntolerance Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter ![]() | US Core Encounter Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal ![]() | US Core Goal Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication ![]() | US Core Medication Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest ![]() | US Core MedicationRequest Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab ![]() | US Core Laboratory Result Observation Profile |
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.8.1 ![]() | ProgressNoteDocumentTypeCode |
Note: links and images are rebased to the (stated) source
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
![]() ![]() | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() ![]() | S | 1..1 | CodeableConcept | type Binding: ProgressNoteDocumentTypeCode (required) |
![]() ![]() ![]() | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Assessment Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Assessments Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Allergies and Intolerances Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
![]() ![]() ![]() ![]() ![]() | 1..1 | Narrative | text | |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinicianâs 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. |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Assessment and plan Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Chief Complaint Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Chief complaint Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Instructions Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Instructions Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 69730-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Interventions Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Interventions provided Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 62387-6 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(List | RequestGroup) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Medications Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | History of medication use Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Nutrition Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Diet and nutrition Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61144-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Objective Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Objective Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Physical Exam Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Physical findings Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Plan of Treatment Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Plan of Treatment Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 |