Back To Index  <<  Back To Templates

pending Template  Progress Note

Template 2.16.840.1.113883.10.20.22.1.9 - ProgressNote
Id 2.16.840.1.113883.10.20.22.1.9
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Document Level Template
Context Pathname //
Open/Closed Open (other than defined elements are allowed)
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.
Used by / Uses
Used by / Uses 15 templates
Uses Template id as Name Version
2.16.840.1.113883.10.20.21.2.1 Containment ObjectiveSection DYNAMIC
2.16.840.1.113883.10.20.22.2.1 Containment MedicationsSectionentriesoptional DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Containment ChiefComplaintSection DYNAMIC
2.16.840.1.113883.10.20.22.2.6 Containment AllergiesSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.9 Containment AssessmentandPlanSection DYNAMIC
2.16.840.1.113883.10.20.22.2.10 Containment PlanofCareSection DYNAMIC
2.16.840.1.113883.10.20.22.2.8 Containment AssessmentSection DYNAMIC
2.16.840.1.113883.10.20.21.2.3 Containment InterventionsSection DYNAMIC
2.16.840.1.113883.10.20.2.10 Containment PhysicalExamSection DYNAMIC
2.16.840.1.113883.10.20.22.2.3 Containment ResultsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.4 Containment VitalSignsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.5 Containment ProblemSectionentriesoptional DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.18 Containment ReviewofSystemsSection DYNAMIC
2.16.840.1.113883.10.20.21.2.2 Containment SubjectiveSection DYNAMIC
2.16.840.1.113883.10.20.22.2.45 Containment InstructionsSection DYNAMIC
Item DT Card Conf Description Label
cda:ClinicalDocument
(ProgressNote)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:7588) such that it conf‑7588
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.1.9
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:17189). conf‑17189
treetree cda:documentationOf
0 .. 1 R SHOULD contain zero or one [0..1] documentationOf (CONF:7603). conf‑7603
treeblank treetree cda:serviceEvent
1 .. 1 M The documentationOf, if present, SHALL contain exactly one [1..1] serviceEvent (CONF:7604). conf‑7604
treeblank treeblank treetree @classCode
1 .. 1 F PCPR
treeblank treeblank treetree cda:templateId
1 .. 1 M This serviceEvent SHALL contain exactly one [1..1] templateId (CONF:9480) such that it 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
0 .. 1 R This serviceEvent SHOULD contain zero or one [0..1] effectiveTime (CONF:9481).

The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element

If a width element is not present, the serviceEvent SHALL include effectiveTime/high

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑9481
  Schematron assert role red error
  test not(cda:documentationOf/cda:serviceEvent) or cda:documentationOf/cda:serviceEvent[count(cda:effectiveTime)=1]
  Message This serviceEvent SHOULD contain zero or one [0..1] effectiveTime (CONF:9481).
  Schematron assert role red error
  test cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:low
  Message The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element
  Schematron assert role red error
  test count(cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:high | cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:width)=1
  Message If a width element is not present, the serviceEvent SHALL include effectiveTime/high
  Schematron assert role red error
  test not(cda:documentationOf/cda:serviceEvent/cda:effectiveTime) or string-length(cda:documentationOf/cda:serviceEvent/cda:effectiveTime//@value)>=8
  Message The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
treetree cda:componentOf
1 .. 1 M SHALL contain exactly one [1..1] componentOf (CONF:7595). conf‑7595
treeblank treetree cda:encompassingEncounter
1 .. 1 M This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:7596). conf‑7596
treeblank treeblank treetree cda:id
1 .. * M This encompassingEncounter SHALL contain at least one [1..*] id (CONF:7597). conf‑7597
treeblank treeblank treetree cda:effectiveTime
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:7598).

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑7598
treeblank treeblank treeblank treetree cda:low
1 .. 1 M This effectiveTime SHALL contain exactly one [1..1] low (CONF:7599). conf‑7599
  Schematron assert role red error
  test string-length(cda:componentOf/cda:encompassingEncounter/cda:effectiveTime//@value)>=8
  Message The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
treeblank treeblank treetree cda:location/healthCareFacility/id
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] location/healthCareFacility/id (CONF:7611). conf‑7611
treetree cda:component
1 .. 1 M SHALL contain exactly one [1..1] component (CONF:9591).

A Progress Note can have either a structuredBody or a nonXMLBody

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

SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.

SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
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:templateId[@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:templateId[@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.
Choice min 1 element(s) and max 1 element(s). Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
treeblank treeblank treetree cda:nonXMLBody
conf‑9591
treeblank treeblank treetree cda:structuredBody
conf‑9591
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.21.2.1']]
0 .. 1 conf‑8770
  Contains 2.16.840.1.113883.10.20.21.2.1 Objective Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.1']]
0 .. 1 conf‑8771
  Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1']]
0 .. 1 conf‑8772
  Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.6']]
0 .. 1 conf‑8773
  Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.9']]
0 .. 1 conf‑8774
  Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.10']]
0 .. 1 conf‑8775
  Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.8']]
0 .. 1 conf‑8776
  Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.21.2.3']]
0 .. 1 conf‑8778
  Contains 2.16.840.1.113883.10.20.21.2.3 Interventions Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.2.10']]
0 .. 1 conf‑8780
  Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.3']]
0 .. 1 conf‑8782
  Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.4']]
0 .. 1 conf‑8784
  Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.5']]
0 .. 1 conf‑8786
  Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.18']]
0 .. 1 conf‑8788
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.21.2.2']]
0 .. 1 conf‑8790
  Contains 2.16.840.1.113883.10.20.21.2.2 Subjective Section (DYNAMIC)
  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:templateId[@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:templateId[@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
treeblank treetree cda:section
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.45']]
0 .. 1 conf‑16806
  Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (DYNAMIC)
treetree cda:code/@code
1 .. 1 M SHALL contain exactly one [1..1] code/@code, which SHALL be selected from ValueSet ProgressNoteDocumentTypeCode 2.16.840.1.113883.11.20.8.1 DYNAMIC (CONF:7589). conf‑7589
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.8.1 ProgressNoteDocumentTypeCode (DYNAMIC)