Template 2.16.840.1.113883.10.20.22.1.9 Progress Note

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.9 - ProgressNote
Id 2.16.840.1.113883.10.20.22.1.9
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑642
Version valid from 2012‑01‑12 status draft
Description 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.
Item DT Card Conf Desc Label
cda:ClinicalDocument
  conf-642
treetree cda:templateId
II 1..1 M conf‑9483
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑7588
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.9
treetree cda:code
1..1 M conf‑7589
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.8.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.8.1"
treetree cda:documentationOf
0..1 R conf‑7603
treeblank treetree cda:serviceEvent/@classCode
1..1 M conf‑7604
treeblank treeblank treetree @code
1..1 F PCPR
treeblank treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.6
treeblank treeblank treetree @displayName
1..1 F Care Provision
treeblank treeblank treetree cda:templateId
II 1..1 M conf‑9480
treeblank treeblank treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.21.3.1
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 R conf‑9481
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
Schematron assert Role red error
Test cda:low
Message
The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element
Schematron assert Role red error
Test count(cda:high | cda:width)=1
Message
If a width element is not present, the serviceEvent SHALL include effectiveTime/high
treetree cda:componentOf
1..1 M conf‑7595
treeblank treetree cda:encompassingEncounter
1..1 M conf‑7596
treeblank treeblank treetree cda:id
II 1..* M conf‑7597
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑7598
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
treeblank treeblank treeblank treetree cda:low
TS 1..1 M conf‑7599
treeblank treeblank treetree cda:location
_cda:healthCareFacility
__cda:id
II 1..1 M conf‑7611
treetree cda:component
1..1 M A Progress Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.9), coded entries are optional
If structuredBody, the component/structuredBody SHALL conform to the section constraints below 		conf‑9591
Schematron assert Role red error
Test count(//cda:structuredBody | cda:nonXMLBody)=1
Message
A Progress Note can have either a structuredBody or a nonXMLBody
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present