Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Progress Note

[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.9]

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.

Progress Note Header Constraints

Progress Note Body Constraints

  1. SHALL contain exactly one [1..1] templateId ( ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.9"
  2. SHALL conform to General Header Constraints template (templateId: 2.16.840.1.113883.10.20.22.1.1) (CONF:9483)
  3. SHALL contain exactly one [1..1] code (CONF:17189), where the @code SHALL be selected from ValueSet ProgressNoteDocumentTypeCode 2.16.840.1.113883.11.20.8.1 DYNAMIC (CONF:17190)
    • The Progress Note limits document type codes to those codes listed in the Progress Note LOINC Document Codes, as of publication of this implementation guide. This is a dynamic value set meaning that these codes may be added to or deprecated by LOINC. The table lists all codes that have the scale DOC (document) and a 'component' referring to "subsequent evaluation notes".

      The Progress Note recommends use of a single document type code, 11506-3 "Subsequent evaluation note", using post-coordination for author or performer, setting, or specialty. Some of the LOINC codes in the Progress Note LOINC Document Codes table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header.  When these 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. Note: The LOINC display name "Subsequent evaluation note" is equivalent to Progress Note.

  4. SHOULD contain zero or one [0..1] documentationOf (CONF:7603)
    1. This documentationOf SHALL contain exactly one [1..1] serviceEvent
      1. This serviceEvent SHALL contain exactly one [1..1] @classCode="PCPR" (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7604)
      2. This serviceEvent SHOULD contain zero or one [0..1] effectiveTime (CONF:9481)
      3. This serviceEvent The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element (CONF:9482)
      4. This serviceEvent If a width element is not present, the serviceEvent SHALL include effectiveTime/ (CONF:10066)
  5. SHALL contain exactly one [1..1] componentOf
    1. This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:7596)
      1. This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:7598)
      2. This encompassingEncounter SHALL contain at least one [1..*] id (CONF:7597)
      3. This encompassingEncounter SHALL contain exactly one [1..1] location
        1. This location SHALL contain exactly one [1..1] healthCareFacility
          1. This healthCareFacility SHALL contain exactly one [1..1] id (CONF:7611)
  6. MAY contain zero or one [0..1] component (CONF:8776)
    1. Contains exactly one [1..1] Assessment Section (templateId: 2.16.840.1.113883.10.20.22.2.8)
  7. MAY contain zero or one [0..1] component (CONF:8775)
    1. Contains exactly one [1..1] Plan Of Care Section (templateId: 2.16.840.1.113883.10.20.22.2.10)
  8. MAY contain zero or one [0..1] component (CONF:8774)
    1. Contains exactly one [1..1] Assessment And Plan Section (templateId: 2.16.840.1.113883.10.20.22.2.9)
  9. MAY contain zero or one [0..1] component (CONF:8773)
    1. Contains exactly one [1..1] Allergies Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.6)
  10. MAY contain zero or one [0..1] component (CONF:8772)
    1. Contains exactly one [1..1] Chief Complaint Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
  11. MAY contain zero or one [0..1] component (CONF:8778)
    1. Contains exactly one [1..1] Interventions Section (templateId: 2.16.840.1.113883.10.20.21.2.3)
  12. MAY contain zero or one [0..1] component (CONF:8771)
    1. Contains exactly one [1..1] Medications Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.1)
  13. MAY contain zero or one [0..1] component (CONF:8770)
    1. Contains exactly one [1..1] Objective Section (templateId: 2.16.840.1.113883.10.20.21.2.1)
  14. MAY contain zero or one [0..1] component (CONF:8780)
    1. Contains exactly one [1..1] Physical Exam Section (templateId: 2.16.840.1.113883.10.20.2.10)
  15. MAY contain zero or one [0..1] component (CONF:8786)
    1. Contains exactly one [1..1] Problem Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.5)
  16. MAY contain zero or one [0..1] component (CONF:8782)
    1. Contains exactly one [1..1] Results Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.3)
  17. MAY contain zero or one [0..1] component (CONF:8788)
    1. Contains exactly one [1..1] Review Of Systems Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.18)
  18. MAY contain zero or one [0..1] component (CONF:8790)
    1. Contains exactly one [1..1] Subjective Section (templateId: 2.16.840.1.113883.10.20.21.2.2)
  19. MAY contain zero or one [0..1] component (CONF:8784)
    1. Contains exactly one [1..1] Vital Signs Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.4)
  20. MAY contain zero or one [0..1] component (CONF:16806)
    1. Contains exactly one [1..1] Instructions Section (templateId: 2.16.840.1.113883.10.20.22.2.45)
  21. SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section (CONF:8704)
  22. SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present (CONF:10069)

Progress Note Example

<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
  <typeId root="2.16.840.1.113883.1.3"/>
  <id root="MDHT" extension="974513096"/>
  <code code="557099262"/>
  <title>TEXT FOR TITLE</title>
  <effectiveTime/>
  <confidentialityCode code="423366893"/>
  <setId root="MDHT" extension="8e8f7d9d-02f5-47cc-b212-eb332a10feff"/>
  <versionNumber value="1"/>
  <recordTarget>
    <typeId root="2.16.840.1.113883.1.3"/>
    <patientRole/>
  </recordTarget>
  <author>
    <typeId root="2.16.840.1.113883.1.3"/>
    <time/>
    <assignedAuthor/>
  </author>
  <custodian/>
  <documentationOf>
    <serviceEvent classCode="PCPR">
      <templateId root="2.16.840.1.113883.10.20.21.3.1"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
    </serviceEvent>
  </documentationOf>
  <componentOf>
    <encompassingEncounter>
      <id root="MDHT" extension="519676635"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <location/>
    </encompassingEncounter>
  </componentOf>
  <component>
    <structuredBody>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="2095547954"/>
          <code code="2009950210"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1957714330"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1736896969"/>
          <code code="1995195288"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1011769201"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1895579913"/>
              <code code="895708626"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
          <entry>
            <encounter>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1765284665"/>
              <code code="603711462"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </encounter>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="153634987"/>
              <code code="1585227207"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </observation>
          </entry>
          <entry>
            <procedure>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1928372750"/>
              <code code="1829978550"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </procedure>
          </entry>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1703045545"/>
              <code code="262053112"/>
              <effectiveTime value="20130627"/>
              <consumable/>
            </substanceAdministration>
          </entry>
          <entry>
            <supply classCode="SPLY">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1068399207"/>
              <code code="1122818124"/>
              <effectiveTime value="20130627"/>
            </supply>
          </entry>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1749438796"/>
              <code code="192501471"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1553738901"/>
          <code code="1252594310"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1352879343"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="780423238"/>
              <code code="1527167844"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1716729085"/>
          <code code="1346654836"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1039880068"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1858910"/>
              <code code="1254251779"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="490191752"/>
          <code code="1166358898"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1742494288"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="175894584"/>
          <code code="77235378"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="2026263929"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1952881711"/>
          <code code="893508625"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="468668908"/>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="510646883"/>
              <code code="677222832"/>
              <effectiveTime value="20130627"/>
              <consumable/>
              <performer/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <precondition/>
            </substanceAdministration>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="600958371"/>
          <code code="773055947"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="468595751"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="469746437"/>
          <code code="1202225717"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="145798339"/>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="2043283426"/>
              <code code="106227555"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship typeCode="COMP"/>
              <entryRelationship typeCode="COMP"/>
              <entryRelationship typeCode="COMP"/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="743639391"/>
              <code code="1669770431"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <author/>
              <entryRelationship typeCode="SUBJ"/>
            </observation>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="158791060"/>
              <code code="2147312556"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1675809650"/>
          <code code="2134093700"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1570159336"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="220509060"/>
              <code code="927254236"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1541420081"/>
          <code code="1065374306"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="2077529595"/>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1416024232"/>
              <code code="297649635"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1395765001"/>
          <code code="995089927"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1810558253"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="774838284"/>
          <code code="629454149"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1131104404"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="453388595"/>
          <code code="38589657"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1820421917"/>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="938386748"/>
              <code code="414702265"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1044751934"/>
          <code code="252843699"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="937650974"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1690655037"/>
              <code code="1379700273"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>