11508-9  Physical therapy Progress notePhysical therapy Progress noteProgress note: Find: Pt: {Setting}: Doc: Physical therapy  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Progress note  Find  Pt  {Setting}  Doc  Physical therapy
  Long Common Name:  Physical therapy Progress note
  Short Name:  PT Progress note

PART DEFINITION/DESCRIPTION(S)
  Part: 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.
 
 

BASIC ATTRIBUTES
  Class/Type: DOC.ONTOLOGY/Clinical
  First Released in Version: 1.0j-a
  Last Updated in Version: 2.58
  Order vs. Obs.: Both
  HL7 Attachment Structure: IG exists
  Status: Active.
Change Reason: Based on Clinical LOINC Committee approval on 8/16/2011, the Component was changed from Subsequent evaluation note to Progress note. The term "Subsequent evaluation" seems to be used infrequently and is more commonly referred to as a Progress note. lso changed class from ATTACH.CLINRPT to DOC.CLINRPT since this term is conformant to the Document Ontology axis values and therefore being placed in this class.

ASSOCIATED OBSERVATIONS

Definition/Description: 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#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81216-4   Progress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 and R2.1 sectionsProgress note - recommended C-CDA R2.0 & R2.1 sections: -: Pt: {Setting}: -:    
       51847-2   Assessment+Plan R    
       51848-0   Assessment R    
       18776-5   Plan of care R    
       48765-2   Allergies O    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported O    
       69730-0   InstructionsInstructionsInstructions: Find: Pt: {Setting}: Doc: {Role} O    
       62387-6   Interventions NarrativeInterventions NarrativeInterventions: Find: Pt: ^Patient: Nar: O    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: O    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: O    
       61149-1   Objective NarrativeObjective NarrativeObjective: Find: Pt: ^Patient: Nar: O    
       29545-1   Physical findings NarrativePhysical findings NarrativePhysical findings: Find: Pt: ^Patient: Nar: Observed O    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported O    
       30954-2   Results O    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported O    
       61150-9   Subjective NarrativeSubjective NarrativeSubjective: Find: Pt: ^Patient: Nar: O    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed O    
 

ASSOCIATED OBSERVATIONS

Definition/Description: 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#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  72225-6   Progress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sectionsProgress note - recommended C-CDA R1.1 sections: -: Pt: {Setting}: -:    
       51847-2   Assessment+Plan R    
       51848-0   Assessment R    
       18776-5   Plan of care R    
       48765-2   Allergies O    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported O    
       69730-0   InstructionsInstructionsInstructions: Find: Pt: {Setting}: Doc: {Role} O    
       62387-6   Interventions NarrativeInterventions NarrativeInterventions: Find: Pt: ^Patient: Nar: O    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: O    
       61149-1   Objective NarrativeObjective NarrativeObjective: Find: Pt: ^Patient: Nar: O    
       29545-1   Physical findings NarrativePhysical findings NarrativePhysical findings: Find: Pt: ^Patient: Nar: Observed O    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported O    
       30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar: O    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported O    
       61150-9   Subjective NarrativeSubjective NarrativeSubjective: Find: Pt: ^Patient: Nar: O    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed O    
 

ASSOCIATED OBSERVATIONS

Definition/Description: 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#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  81243-8   Enhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 and R1.1 sectionsEnhanced encounter note - recommended CDP Set 1 R1.0 & R1.1 sections: -: Pt: {Setting}: -:    
       77599-9   Additional documentationAdditional documentationAdditional documentation: Find: Pt: {Setting}: Doc: {Role} R    
       77598-1   Externally defined clinical data elements DocumentExternally defined clinical data elements DocumentExternally defined clinical data elements: Find: Pt: {Setting}: Doc: {Role} R    
       47420-5   Functional status assessment noteFunctional status assessment noteFunctional status assessment note: Find: Pt: {Setting}: Doc: {Role} R    
       77597-3   Orders placed DocumentOrders placed DocumentOrders placed: Find: Pt: {Setting}: Doc: {Role} R    
       18776-5   Plan of care notePlan of care notePlan of care note: Find: Pt: {Setting}: Doc: {Role} R    
       29762-2   Social history NarrativeSocial history NarrativeSocial history: Find: Pt: ^Patient: Nar: R    
       77596-5   Transportation summary DocumentTransportation summary DocumentTransportation summary: Find: Pt: {Setting}: Doc: {Role} R    
       42348-3   Advance directivesAdvance directivesAdvance directives: Find: Pt: {Setting}: Doc: {Role} O    
       48765-2   Allergies R    
       51847-2   Evaluation +​ Plan noteEvaluation +​ Plan noteEvaluation+​Plan note: Find: Pt: {Setting}: Doc: {Role} R    
       51848-0   Evaluation noteEvaluation noteEvaluation note: Find: Pt: {Setting}: Doc: {Role} R    
       46239-0   Chief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit NarrativeChief complaint+​Reason for visit: Find: Pt: ^Patient: Nar: R    
       10154-3   Chief complaint Narrative - ReportedChief complaint Narrative - ReportedChief complaint: Find: Pt: ^Patient: Nar: Reported R    
       46240-8   History of Hospitalizations+​Outpatient visits NarrativeHistory of Hospitalizations+​Outpatient visits NarrativeHospitalizations+​Outpatient visits: Hx: Pt: ^Patient: Nar: R    
       10157-6   History of family member diseases NarrativeHistory of family member diseases NarrativeHistory of family member diseases: Hx: Pt: ^Family member: Nar: R    
       10210-3   Physical findings of General status NarrativePhysical findings of General status NarrativePhysical findings: Find: Pt: General status: Nar: Observed R    
       61146-7   Goals NarrativeGoals NarrativeGoals: Find: Pt: ^Patient: Nar: R    
       75310-3   Health concerns DocumentHealth concerns DocumentHealth concerns: Find: Pt: ^Patient: Doc: R    
       11383-7   Patient problem outcome NarrativePatient problem outcome NarrativePatient problem outcome: Find: Pt: ^Patient: Nar: R    
       11348-0   History of Past illness NarrativeHistory of Past illness NarrativePast illness: Hx: Pt: ^Patient: Nar: R    
       10164-2   History of Present illness NarrativeHistory of Present illness NarrativePresent illness: Hx: Pt: ^Patient: Nar: R    
       11369-6   History of Immunization NarrativeHistory of Immunization NarrativeImmunization: Hx: Pt: ^Patient: Nar: R    
       69730-0   InstructionsInstructionsInstructions: Find: Pt: {Setting}: Doc: {Role} R    
       62387-6   Interventions NarrativeInterventions NarrativeInterventions: Find: Pt: ^Patient: Nar: R    
       46264-8   History of medical device useHistory of medical device useHistory of medical device use: Find: Pt: {Setting}: Doc: {Role} R    
       10160-0   History of Medication use NarrativeHistory of Medication use NarrativeMedication use: Hx: Pt: ^Patient: Nar: R    
       10190-7   Mental status NarrativeMental status NarrativeMental status: Find: Pt: ^Patient: Nar: Observed R    
       61144-2   Diet and nutrition NarrativeDiet and nutrition NarrativeDiet and nutrition: Find: Pt: ^Patient: Nar: R    
       61149-1   Objective NarrativeObjective NarrativeObjective: Find: Pt: ^Patient: Nar: R    
       48768-6   Payment sources DocumentPayment sources DocumentPayment sources: Find: Pt: ^Patient: Doc: R    
       29545-1   Physical findings NarrativePhysical findings NarrativePhysical findings: Find: Pt: ^Patient: Nar: Observed R    
       11450-4   Problem list - ReportedProblem list - ReportedProblem list: Find: Pt: ^Patient: Nom: Reported R    
       47519-4   History of Procedures DocumentHistory of Procedures DocumentHistory of procedures: Find: Pt: {Setting}: Doc: {Role} R    
       42349-1   Reason for referral (narrative)Reason for referral (narrative)Reason for referral: Find: Pt: ^Patient: Nar: R    
       29299-5   Reason for visit NarrativeReason for visit NarrativeReason for visit: Find: Pt: ^Patient: Nar: R    
       30954-2   Relevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests/​laboratory data NarrativeRelevant diagnostic tests &or laboratory data: Find: Pt: ^Patient: Nar: R    
       10187-3   Review of systems Narrative - ReportedReview of systems Narrative - ReportedReview of systems: Find: Pt: ^Patient: Nar: Reported R    
       61150-9   Subjective NarrativeSubjective NarrativeSubjective: Find: Pt: ^Patient: Nar: R    
       8716-3   Vital signsVital signsVital signs: Find: Pt: ^Patient: Nar: Observed R    
 

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  26443-2 Clinical reports.non lab claims attachment
  

MEMBER OF THESE EQUIVALENCE GROUPS
  LG38948-2  Physical therapy|ANYTypeOfService|ANYKindOfNote|ANYSetting
  LG38741-1  Progress note|ANYRole|ANYSetting
  LG41826-5  {Setting}|ANYTypeofService|ANYKindofDocument|ANYRole|ANYSubjectMatterDomain

PARTS

Part Type    Part No.  Part Name   
Component   LP74253-3  Progress note 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP32887-9  {Setting} 
Scale   LP32888-7  Doc 
Method   LP6449-5  Physical therapy 
Fragments for synonyms   LP183649-5  note 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  病程记录:发现:时间点:{环境}:文档型:物理疗法病程记录:发现:时间点:{环境}:文档型:物理疗法
  Dutch (NETHERLANDS)  (From: Regenstrief-generated full translation based on part translation provided by NVKC, Dutch Society for Clinical Chemistry and Laboratory Medicine, The Netherlands)
 
  voortgangsrapport:bevinding:moment:{instelling}:document:lichamelijke oefeningvoortgangsrapport:bevinding:moment:{instelling}:document:lichamelijke oefening
  French (BELGIUM)  (From: Regenstrief-generated full translation based on part translation provided by Jean M. Prevost, MD, Biopathology)
 
  Note de progrès:Observation:Temps ponctuel:{réglages}:Document:Traitement physiqueNote de progrès:Observation:Temps ponctuel:{réglages}:Document:Traitement physique
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Progresso, nota:Osservazione:Pt:{Setting}:Doc:Terapia fisicaProgresso, nota:Osservazione:Pt:{Setting}:Doc:Terapia fisica
  Spanish (ARGENTINA)  (From: Conceptum Medical Terminology Center)
 
  SUBSEQUENT EVALUATION NOTE:hallazgo:punto en el tiempo:{contexto}:Documento:fisioterapiaSUBSEQUENT EVALUATION NOTE:hallazgo:punto en el tiempo:{contexto}:Documento:fisioterapia

RELATED NAMES
  DOC.ONT Finding Random
  Document Findings subsequent evaluation
  Encounter notes subsequent visit evaluation
  Evaluation and management Point in time Visit note
  Evaluation and management note PT  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 7:26:45 PM
  Long Common Name: Physical therapy Progress note
  Shortname: PT Progress note
  Fully Specified Name: Progress note: Find: Pt: {Setting}: Doc: Physical therapy
     
  Component Word Count: 2
  ID: 1676
  # of Panel Elements: 40
  Status (Raw): ACTIVE