89816-3
Trauma Progress note
Active
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
Fully-Specified Name
- Component
- Progress note
- Property
- Find
- Time
- Pt
- System
- {Setting}
- Scale
- Doc
- Method
- Trauma
Additional Names
- Short Name
- Trauma Prog note
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 Narrative | 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 | 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 Narrative | O | ||
| Indent11450-4 | Problem list - Reported | O | ||
| Indent30954-2 | Relevant diagnostic tests/laboratory data Narrative | O | ||
| Indent10187-3 | Review of systems Narrative - Reported | O | ||
| Indent61150-9 | Subjective Narrative | O | ||
| Indent8716-3 | Vital signs | 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 Narrative | R | ||
| Indent77596-5 | Transportation summary Document | R | ||
| Indent42348-3 | Advance 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 Narrative | 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 Narrative | R | ||
| Indent10164-2 | History of Present illness Narrative | R | ||
| Indent11369-6 | History of Immunization Narrative | 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 Narrative | 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 Narrative | R | ||
| Indent10187-3 | Review of systems Narrative - Reported | R | ||
| Indent61150-9 | Subjective Narrative | R | ||
| Indent8716-3 | Vital signs | R |
Basic Attributes
- Class
- DOC.ONTOLOGY
- Type
- Clinical
- First Released
- Version 2.65
- Last Updated
- Version 2.73
- Order vs. Observation
- Both
- HL7® Attachment Structure
- Implementation guide exists
Member of these Groups Get Info
| LOINC Group | Group Name |
|---|---|
| LG41826-5 | {Setting}| |
| LG38741-1 | Progress note| |
| LG39060-5 | Trauma| |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-MX | Spanish (Mexico) | Nota de progreso: |
| it-IT | Italian (Italy) | Progresso, nota: Synonyms: Documentazione dell''ontologia Nota di progresso; |
| zh-CN | Chinese (China) | 病程记录: Synonyms: 临床文档型; |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
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