Template

Show index

Template Progress Note (V3) 2015‑08‑01

Id2.16.840.1.113883.10.20.22.1.9Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameProgressNoteV3Display NameProgress Note (V3)
Description
This template 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.
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 17 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Containmentdraft Chief Complaint Section (2.1)2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.18Containmentdraft Review of Systems Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.2.10Containmentdraft Physical Exam Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.21.2.1Containmentdraft Objective Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.21.2.2Containmentdraft Subjective Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.21.2.3Containmentdraft Interventions Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.1Containmentdraft Medications Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.3Containmentdraft Results Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.4Containmentdraft Vital Signs Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.5Containmentdraft Problem Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6Containmentdraft Allergies and Intolerances Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.8Containmentdraft Assessment Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.9Containmentdraft Assessment and Plan Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Treatment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.45Containmentdraft Instructions Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.57Containmentdraft Nutrition Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.5.3Containmentdraft US Realm Date and Time (DT.US.FIELDED) (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (V3) (2015‑08‑01)
Version: template 2.16.840.1.113883.10.20.22.1.9 Progress Note (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
CWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALL include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32942).
ProgdotsteV3
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.9
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-7588) such that itCONFdots7588
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.9CONFdots0052
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.9" (CONF:1198-10052).
@extension
st1 … 1F2015-08-01CONFdots2521
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32521).
cda:code
1 … 1SHALL contain exactly one [1..1] code (CONF:1198-17189).

The Progress Note recommends use of a single document type code, 11506-3 "Subsequent evaluation note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. 		CONFdots7189
cda:documentationOf
0 … 1RSHOULD contain zero or one [0..1] documentationOf (CONF:1198-7603).

A documentationOf can contain a serviceEvent to further specialize the act inherent in the ClinicalDocument/code. In a Progress Note, a serviceEvent can represent the event of writing the Progress Note. The serviceEvent/effectiveTime is the time period the note documents.		CONFdots7603
cda:serviceEvent
1 … 1MContains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13)CONFdots7604
@classCode
cs1 … 1FPCPRCONFdots6420
 This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" Care Provision (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1198-26420).
cda:templateId
II1 … 1MThis serviceEvent SHALL contain exactly one [1..1] templateId (CONF:1198-9480) such that itCONFdots9480
@root
uid1 … 1F2.16.840.1.113883.10.20.21.3.1
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.21.3.1" (CONF:1198-10068).
cda:componentOf
1 … 1MSHALL contain exactly one [1..1] componentOf (CONF:1198-7595).

The Progress Note is always associated with an encounter by the componentOf/encompassingEncounter element in the header. The effectiveTime element for an encompassingEncounter represents the time or time interval in which the encounter took place. A single encounter may contain multiple Progress Notes; hence the effectiveTime elements for a Progress Note (recorded in serviceEvent) and for an encounter (recorded in encompassingEncounter) represent different time intervals. For outpatient encounters that are a point in time, set effectiveTime/high, effectiveTime/low, and effectiveTime/@value to the same time. All visits take place at a specific location. When available, the location ID is included in the encompassingEncounter/location/healthCareFacility/id element.

CONFdots7595
cda:encompassingEncounter
1 … 1MContains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13)CONFdots7596
cda:id
II1 … *This encompassingEncounter SHALL contain at least one [1..*] id (CONF:1198-7597).CONFdots7597
cda:location
1 … 1MThis encompassingEncounter SHALL contain exactly one [1..1] location (CONF:1198-30879).CONFdots0879
cda:healthCareFacility
1 … 1MThis location SHALL contain exactly one [1..1] healthCareFacility (CONF:1198-30880).CONFdots0880
cda:id
II1 … *This healthCareFacility SHALL contain at least one [1..*] id (CONF:1198-30881).CONFdots0881
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:1198-9591).CONFdots9591
cda:structuredBody
1 … 1MThis component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30617).

In this template (templateId 2.16.840.1.113883.10.20.22.1.9.2), coded entries are optional		CONFdots0617
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13)CONFdots0618
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09)CONFdots0620
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09)CONFdots0622
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.6 Allergies and Intolerances Section (entries optional) (V3) (2015‑08‑01)CONFdots0624
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2015‑08‑13)CONFdots0626
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.21.2.3 Interventions Section (V3) (2015‑08‑01)CONFdots0628
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (V2) (2014‑06‑09)CONFdots0639
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (V2) (2014‑06‑09)CONFdots0641
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.21.2.1 Objective Section (2015‑08‑13)CONFdots0643
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01)CONFdots0645
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (V3) (2015‑08‑01)CONFdots0647
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (V3) (2015‑08‑01)CONFdots0649
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13)CONFdots0651
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.21.2.2 Subjective Section (2015‑08‑13)CONFdots0653
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (V3) (2015‑08‑01)CONFdots0655
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.57 Nutrition Section (2015‑08‑13)CONFdots2626
 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