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Template Progress Note 2013‑01‑31

Id2.16.840.1.113883.10.20.22.1.9Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameProgressNoteDisplay NameProgress Note
Description
A 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 1833(e) defines the requirements of a Medicare Progress Report.
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 14 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transactionfinal Progress Note (Release 1.1)2013‑01‑31
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Containmentdraft Chief Complaint Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.18Containmentdraft Review of Systems Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.2.10Containmentdraft Physical Exam Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.21.2.1Containmentdraft Objective Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.21.2.2Containmentdraft Subjective Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.21.2.3Containmentdraft Interventions Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1Containmentdraft Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.3Containmentdraft Results Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.4Containmentdraft Vital Signs Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.5Containmentdraft Problem Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6Containmentdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.8Containmentdraft Assessment Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.9Containmentdraft Assessment and Plan Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Care Section (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
ProgdotsNote
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:7588) such that itconf‑7588
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.9confdots0052
cda:code
1 … 1RSHALL contain exactly one [1..1] code (CONF:17189).
SHALL contain exactly one [1..1] code/@code, which SHALL be selected from ValueSet ProgressNoteDocumentTypeCode 2.16.840.1.113883.11.20.8.1 DYNAMIC (CONF:7589).
conf‑17189 / conf‑7589
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.8.1 ProgressNoteDocumentTypeCode (DYNAMIC)
cda:documentationOf
0 … 1RSHOULD contain zero or one [0..1] documentationOf (CONF:7603).conf‑7603
cda:serviceEvent
1 … 1MThe documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:7604).conf‑7604
@classCode
cs1 … 1FPCPRconfdots6420
cda:templateId
II1 … 1MThis serviceEvent SHALL contain exactly one [1..1] templateId (CONF:9480) such that itconf‑9480
@root
uid1 … 1F2.16.840.1.113883.10.20.21.3.1confdots0068
cda:effectiveTime
IVL_TS0 … 1RThis serviceEvent SHOULD contain zero or one [0..1] effectiveTime (CONF:9481).

The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element

If a width element is not present, the serviceEvent SHALL include effectiveTime/high

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑9481
 Schematron assertrolered error 
 testnot(.//@value[not(parent::cda:width)][string-length()<8]) 
 MessageThe content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) 
cda:low
1 … 1RThe serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element.conf‑9481
Choice1 … 1
If a width element is not present, the serviceEvent SHALL include effectiveTime/high
Elements to choose from:
  • cda:width
  • cda:high
cda:width
PQconf‑9481
cda:high
conf‑9481
cda:componentOf
1 … 1MSHALL contain exactly one [1..1] componentOf (CONF:7595).conf‑7595
cda:encompassingEncounter
1 … 1MThis componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:7596).conf‑7596
cda:id
II1 … *RThis encompassingEncounter SHALL contain at least one [1..*] id (CONF:7597).conf‑7597
cda:effectiveTime
1 … 1MThis encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:7598).

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑7598
 Schematron assertrolered error 
 testnot(.//@value[not(parent::cda:width)][string-length()<8]) 
 MessageThe content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) 
cda:low
1 … 1RThis effectiveTime SHALL contain exactly one [1..1] low (CONF:7599).conf‑7599
cda:location
1 … 1MThis encompassingEncounter SHALL contain exactly one [1..1] location/healthCareFacility/id (CONF:7611).conf‑7611
cda:healthCareFacility
1 … 1Rconf‑7611
cda:id
II1 … *Rconf‑7611
cda:component
1 … 1RSHALL contain exactly one [1..1] component (CONF:9591).

A Progress Note can have either a structuredBody or a nonXMLBody

A Progress Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.9), coded entries are optional

If structuredBody, the component/structuredBody SHALL conform to the section constraints below

SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.

SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
conf‑9591
Choice1 … 1Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
cda:nonXMLBody
conf‑9591
cda:structuredBody
conf‑9591
 Schematron assertrolered error 
 test//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'] or (//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] and //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) 
 MessageSHALL include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan Section (2.16.840.1.113883.10.20.22.2.10). 
 Schematron assertrolered error 
 testnot(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9']) or ( not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8']) and not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) ) 
 MessageSHALL NOT include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9) when an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Care Section (2.16.840.1.113883.10.20.22.2.10) are present 
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.21.2.1 Objective Section (2013‑01‑31)conf‑8770
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (2013‑01‑31)conf‑8771
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31)conf‑8772
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (2013‑01‑31)conf‑8773
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (2013‑01‑31)conf‑8774
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31)conf‑8775
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2013‑01‑31)conf‑8776
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.21.2.3 Interventions Section (2013‑01‑31)conf‑8778
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (2013‑01‑31)conf‑8780
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (2013‑01‑31)conf‑8782
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (2013‑01‑31)conf‑8784
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (2013‑01‑31)conf‑8786
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2013‑01‑31)conf‑8788
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.21.2.2 Subjective Section (2013‑01‑31)conf‑8790