Health Story: Progress Note

This page will support the development of the Progress Note Draft Standard for Trial Use (DSTU) for the October 2010 ballot cycle.

This project will design a Progress Note in XML as a constraint on HL7 v3 CDA r2. A Progress Note documents patient’s clinical status during a hospitalization or outpatient visit. The project will review current Progress Note usage and will examine industry precedents and requirements.

Recurring meeting: Tuesday @ 11:00 AM EST - 12:30 PM EST

Conference line: Phone Number: 770-657-9270 Participant Passcode: 310940

Goto Meeting: Progress Note Goto Meeting ID: 823-506-059

Draft IG and Sample

Coming soon!

Development

Progress Note Definitions

Mosby’s medical dictionary:
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. Progress notes may follow the problem-oriented medical record format. The physician's progress notes usually focus on the medical or therapeutic aspects of the patient's condition and care. The nurse's progress notes, although recording the medical conditions of the patient, usually focus on the objectives stated in the nursing care plan. These objectives may include responses to prescribed treatments, the ability to perform activities of daily living, and acceptance or understanding of a particular condition or treatment. Progress notes in an in-hospital setting are recorded daily. Those in a clinic or office setting are usually preceded by an episodic or interval history and are recorded as accounts of each visit.

Taber’s medical dictionary:
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. In patients who are not critically ill, a note concerning progress may be made daily or less frequently; for patients in critical care, notes may be made hourly. It is important that each note be clearly written, the date and time recorded, and the note signed.

Header Review

General Header Sample XML
Header Comparison (includes H&P, OpNote, and DS Headers)

Proposed heuristic for LOINC document codes: ALL LOINC codes that are evaluation and management doc codes identified as “subsequent evaluation notes”.
LOINC Codes for discussion (courtesy of FEI)

Body Review

Sample Progress Notes (courtesy of MedEDocs)

Statistical Section Analysis (courtesy of M*Modal)

Health Story section crosswalk

Reference Material

Project Scope Statement

Pertinent CDA Guides

• Care Record Summary (CRS)
• Consult Notes
• Discharge Summary
• History and Physical (H&P) Notes
• Imaging Integration; Basic Imaging Reports in CDA and DICOM (membership required)
• Operative Notes

Education

Quick Start Guides

• CDA Quick Start Guide (v1.5)

This Quick Start Guide supports implementers working with simple CDA documents. It covers required elements in the CDA header and body and explains fundamental concepts including the CDA approach to identifiers, vocabulary and data types.

• Continuity of Care Document (CCD) Quick Start Guide (v1.0)

This Quick Start Guide is for implementers working with the Continuity of Care Document (CCD). If not already familiar with the underlying Clinical Document Architecture Release 2.0 (CDA R2) standard, readers should also take advantage of the CDA Quick Start Guide available here.

• Care Record Summary (CRS) Quick Start Guide (v1.0)

This Quick Start Guide is for implementers working with the Care Record Summary (CRS).

Agendas and Meeting Minutes

• Header design and initial section analysis agenda 6/29/2010
• Header design meeting minutes 6/22/2010
• Kickoff meeting minutes 6/16/2010