StructureDefinition-2.16.840.1.113883.10.20.22.1.9

Sourcehl7.cda.us.ccdar2dot2#current:Consolidated CDA Release 2.1 StructureDefinition Publication (v5.0.0)
resourceTypeStructureDefinition
id2.16.840.1.113883.10.20.22.1.9
canonicalhttp://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.9
version2.2
statusactive
publisherHealth Level Seven
nameProgressNote
titleProgress Note
date2021-11-24T17:43:01+00:00
descriptionThis template represents a patients clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. Tabers 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. Mosbys 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.
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeClinicalDocument
derivationconstraint
basehttp://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.1
Usages(none)
Name Flags Card. Type Description & Constraints doco
. . ClinicalDocument USRealmHeader
. . . Slices for templateId Slice: Unordered, Open by value:root, value:extension
. . . . templateId:secondary C 1..1 1198-32942: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32942).
. . . . . root 1..1 Required Pattern: 2.16.840.1.113883.10.20.22.1.9
. . . . . extension 1..1 Required Pattern: 2015-08-01
. . . code 1..1 The Progress Note recommends use of a single document type code, 11506-3 "Subsequent evaluation note", with further specification provided by author or performer, setting, or specialty. When 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.
. . . . code 1..1 Binding: todo ( required )
. . . documentationOf 0..1 A documentationOf can contain a serviceEvent to further specialize the act inherent in the ClinicalDocument/code. In a Progress Note, a serviceEvent can represent the event of writing the Progress Note. The serviceEvent/effectiveTime is the time period the note documents.
. . . . serviceEvent 1..1
. . . . . classCode 1..1 Required Pattern: PCPR
. . . . . Slices for templateId Slice: Unordered, Open by value:root
. . . . . . templateId:secondary 1..1
. . . . . . . root 1..1 Required Pattern: 2.16.840.1.113883.10.20.21.3.1
. . . . . effectiveTime C 0..1 http://hl7.org/fhir/cda/StructureDefinition/IVL-TS 1198-9482: The serviceEvent/effectiveTime element **SHOULD** be present with effectiveTime/low element (CONF:1198-9482).
1198-10066: If a width element is not present, the serviceEvent **SHALL** include effectiveTime/high (CONF:1198-10066).
. . . componentOf 1..1 The Progress Note is always associated with an encounter by the componentOf/encompassingEncounter element in the header. The effectiveTime element for an encompassingEncounter represents the time or time interval in which the encounter took place. A single encounter may contain multiple Progress Notes; hence the effectiveTime elements for a Progress Note (recorded in serviceEvent) and for an encounter (recorded in encompassingEncounter) represent different time intervals. For outpatient encounters that are a point in time, set effectiveTime/high, effectiveTime/low, and effectiveTime/@value to the same time. All visits take place at a specific location. When available, the location ID is included in the encompassingEncounter/location/healthCareFacility/id element.
. . . . encompassingEncounter 1..1
. . . . . id 1..*
. . . . . effectiveTime 1..1 http://hl7.org/fhir/cda/StructureDefinition/IVL-TS
. . . . . . low 1..1
. . . . . location 1..1
. . . . . . healthCareFacility 1..1
. . . . . . . id 1..*
. . . component 1..1
. . . . structuredBody C 1..1 In this template (templateId 2.16.840.1.113883.10.20.22.1.9.2), coded entries are optional
1198-30657: This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30657).
1198-30658: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30658).
. . . . . Slices for component Slice: Unordered, Open by value:ClinicalDocument.section
. . . . . . component:component1 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component2 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component3 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component4 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component5 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component6 0..1
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. . . . . . component:component7 0..1
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. . . . . . component:component8 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component9 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component10 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component11 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component12 0..1
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. . . . . . component:component13 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component14 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component15 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section
. . . . . . component:component16 0..1
. . . . . . . section 1..1 http://hl7.org/fhir/cda/StructureDefinition/Section

doco Documentation for this format

Produced 08 Sep 2023