Difference between revisions of "Health Story: Progress Note"
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=====Progress Note Definitions===== | =====Progress Note Definitions===== | ||
| − | ;Mosby’s medical dictionary: | + | ;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. | :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: | + | ;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. | :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. | ||
Revision as of 16:22, 1 February 2011
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: https://www2.gotomeeting.com/join/737419994
Contents
Draft IG and Sample
Draft DSTU and sample file pre-ballot -- This is a full draft ballot of all material discussed through 8/4.
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, DS, and proposed Progress Note 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
Proposed Progress Note Sections
Sample Progress Notes (courtesy of MedEDocs)
Statistical Section Analysis (courtesy of M*Modal)
Health Story section crosswalk
College of Registered Nurses of British Columbia’s (CRNBC)- Practice Support- Nursing Documentation (pg 18)
Progress notes (nurses’ notes) are used to communicate nursing assessments, interventions carried out, and the impact of these interventions on client outcomes. In addition, progress notes are intended to include: client assessments prior to and following administration of PRN medications; information reported to a physician or other health care provider and, when appropriate, that provider’s response; all client teaching; all discharge planning, including instructions given to the client and/or family and planned community follow-up; all pertinent data collected in the course of providing care, including data collected through technology such as monitoring devices (e.g., strips produced during cardiac or fetal monitoring); and advocacy undertaken by the nurse on behalf of the client.
Reference Material
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
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.
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.
This Quick Start Guide is for implementers working with the Care Record Summary (CRS).
Agendas and Meeting Minutes
- DSTU ballot prep meeting minutes 8/10/2010
- DSTU review meeting minutes 8/3/2010
- Review of section cardinality meeting minutes 7/20/2010
- Review of Header constraints in IG Header and section proposals meeting minutes 7/13/2010
- Header wrap-up and section analysis meeting minutes
- Header design and initial section analysis meeting minutes 6/29/2010
- Header design meeting minutes 6/22/2010
- Kickoff meeting minutes 6/16/2010
