description: This profile represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.\n\nTaber'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.\n\nMosby'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.\n\nA 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.
package_name: hl7.fhir.us.ccda
derivation: constraint
name: ProgressNote
type: Composition
elements:
  type:
    short: type
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.8.1'}
    mustSupport: true
    index: 0
  section:
    index: 1
    slicing:
      rules: open
      discriminator:
      - {path: code, type: value}
      min: null
      slices:
        problems_section:
          match:
            code:
              coding:
              - {code: 11450-4, system: 'http://loinc.org'}
          schema:
            label: Problems Section
            short: Problems Section
            mustSupport: true
            index: 60
            elements:
              title: {short: title, mustSupport: true, index: 61}
              code:
                label: Problem list
                short: Problem list
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 11450-4, system: 'http://loinc.org'}
                index: 62
              text: {short: text, mustSupport: true, index: 63}
              entry:
                short: entry
                index: 64
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    problem_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 65
            required: [text, title, code]
        allergies_and_intolerances_section:
          match:
            code:
              coding:
              - {code: 48765-2, system: 'http://loinc.org'}
          schema:
            label: Allergies and Intolerances Section
            short: Allergies and Intolerances Section
            mustSupport: true
            index: 6
            elements:
              title: {short: title, mustSupport: true, index: 7}
              code:
                label: Allergies, adverse reactions, alerts
                short: Allergies, adverse reactions, alerts
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 48765-2, system: 'http://loinc.org'}
                index: 8
              text: {short: text, index: 9}
              entry:
                short: entry
                index: 10
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    allergies_and_intolerances_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance']
                        index: 11
            required: [text, title, code]
        chief_complaint_section:
          match:
            code:
              coding:
              - {code: 10154-3, system: 'http://loinc.org'}
          schema:
            label: Chief Complaint Section
            short: Chief Complaint Section
            mustSupport: true
            index: 18
            elements:
              title: {short: title, mustSupport: true, index: 19}
              code:
                label: Chief complaint
                short: Chief complaint
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10154-3, system: 'http://loinc.org'}
                index: 20
              text: {short: This section contains only human readable content, mustSupport: true, index: 21}
            required: [text, title, code]
        assessment_and_plan_section:
          match:
            code:
              coding:
              - {code: 51847-2, system: 'http://loinc.org'}
          schema:
            label: Assessment and Plan Section
            short: !!binary |-
              QXNzZXNzbWVudCBhbmQgUGxhbiBTZWN0aW9uLiBUaGlzIHNlY3Rpb24gcmVwcmVzZW50cyB0aGUgY2xpbmljaWFuw6LCgMKZcyBjb25jbHVzaW9ucyBhbmQgd29ya2luZyBhc3N1bXB0aW9ucyB0aGF0IHdpbGwgZ3VpZGUgdHJlYXRtZW50IG9mIHRoZSBwYXRpZW50LiBUaGUgQXNzZXNzbWVudCBhbmQgUGxhbiBTZWN0aW9uIG1heSBiZSBjb21iaW5lZCBvciBzZXBhcmF0ZWQgdG8gbWVldCBsb2NhbCBwb2xpY3kgcmVxdWlyZW1lbnRzLg==
            mustSupport: true
            index: 12
            elements:
              title: {short: title, mustSupport: true, index: 13}
              code:
                label: Assessment and plan
                short: Assessment and plan
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 51847-2, system: 'http://loinc.org'}
                index: 14
              text: {short: text, mustSupport: true, index: 15}
              entry:
                index: 16
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    assessment_and_plan_entry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition']
                        index: 17
            required: [text, title, code]
        nutrition_section:
          match:
            code:
              coding:
              - {code: 61144-2, system: 'http://loinc.org'}
          schema:
            label: Nutrition Section
            short: Nutrition Section
            mustSupport: true
            index: 38
            elements:
              title: {short: title, mustSupport: true, index: 39}
              code:
                label: Diet and nutrition
                short: Diet and nutrition
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 61144-2, system: 'http://loinc.org'}
                index: 40
              text: {short: text, mustSupport: true, index: 41}
              entry:
                short: entry
                mustSupport: true
                index: 42
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    nutrition_entry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/Observation']
                        index: 43
            required: [text, title, code]
        results_section:
          match:
            code:
              coding:
              - {code: 30954-2, system: 'http://loinc.org'}
          schema:
            label: Results Section
            short: Results Section
            mustSupport: true
            index: 66
            elements:
              title: {short: title, mustSupport: true, index: 67}
              code:
                label: Relevant diagnostic tests and/or laboratory data
                short: Relevant diagnostic tests and/or laboratory data
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 30954-2, system: 'http://loinc.org'}
                index: 68
              text: {short: text, mustSupport: true, index: 69}
              entry:
                short: entry
                mustSupport: true
                index: 70
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    results_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-lab']
                        index: 71
            required: [text, title, code]
        instructions_section:
          match:
            code:
              coding:
              - {code: 69730-0, system: 'http://loinc.org'}
          schema:
            label: Instructions Section
            short: Instructions Section
            mustSupport: true
            index: 22
            elements:
              title: {short: title, mustSupport: true, index: 23}
              code:
                label: Instructions
                short: Instructions
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 69730-0, system: 'http://loinc.org'}
                index: 24
              text: {short: This section contains only human readable content, mustSupport: true, index: 25}
            required: [text, title, code]
        subjective_section:
          match:
            code:
              coding:
              - {code: 61150-9, system: 'http://loinc.org'}
          schema:
            label: Subjective Section
            short: Subjective Section
            mustSupport: true
            index: 76
            elements:
              title: {short: title, mustSupport: true, index: 77}
              code:
                label: Subjective
                short: Subjective
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 61150-9, system: 'http://loinc.org'}
                index: 78
              text: {short: This section contains only human readable content, mustSupport: true, index: 79}
            required: [text, title, code]
        medications_section:
          match:
            code:
              coding:
              - {code: 10160-0, system: 'http://loinc.org'}
          schema:
            label: Medications Section
            short: Medications Section
            mustSupport: true
            index: 32
            elements:
              title: {short: title, mustSupport: true, index: 33}
              code:
                label: History of medication use
                short: History of medication use
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10160-0, system: 'http://loinc.org'}
                index: 34
              text: {short: text, mustSupport: true, index: 35}
              entry:
                short: entry
                index: 36
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    medications_entry:
                      match: {}
                      schema:
                        type: Reference
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest']
                        index: 37
            required: [text, title, code]
        plan_of_treatment_section:
          match:
            code:
              coding:
              - {code: 18776-5, system: 'http://loinc.org'}
          schema:
            label: Plan of Treatment Section
            short: Plan of Treatment Section
            mustSupport: true
            index: 54
            elements:
              title: {short: title, mustSupport: true, index: 55}
              code:
                label: Plan of Treatment
                short: Plan of Treatment
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 18776-5, system: 'http://loinc.org'}
                index: 56
              text: {short: text, mustSupport: true, index: 57}
              entry:
                short: entry
                index: 58
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    sliceEntry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        refers: ['http://hl7.org/fhir/StructureDefinition/Appointment', 'http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/CommunicationRequest', 'http://hl7.org/fhir/StructureDefinition/DeviceRequest', 'http://hl7.org/fhir/StructureDefinition/NutritionOrder', 'http://hl7.org/fhir/StructureDefinition/RequestGroup', 'http://hl7.org/fhir/StructureDefinition/ServiceRequest', 'http://hl7.org/fhir/StructureDefinition/Task', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest']
                        index: 59
            required: [text, title, code]
        review_of_systems_section:
          match:
            code:
              coding:
              - {code: 10187-3, system: 'http://loinc.org'}
          schema:
            label: Review of Systems Section
            short: Review of Systems Section
            mustSupport: true
            index: 72
            elements:
              title: {short: title, mustSupport: true, index: 73}
              code:
                label: Review of systems
                short: Review of systems
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 10187-3, system: 'http://loinc.org'}
                index: 74
              text: {short: This section contains only human readable content, mustSupport: true, index: 75}
            required: [text, title, code]
        vital_signs_section:
          match:
            code:
              coding:
              - {code: 8716-3, system: 'http://loinc.org'}
          schema:
            label: Vital Signs Section
            short: Vital Signs Section
            mustSupport: true
            index: 80
            elements:
              title: {short: title, mustSupport: true, index: 81}
              code:
                label: Vital signs
                short: Vital signs
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 8716-3, system: 'http://loinc.org'}
                index: 82
              text: {short: text, mustSupport: true, index: 83}
              entry:
                short: entry
                index: 84
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    vital_signs_entry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/vitalsigns']
                        index: 85
            required: [text, title, code]
        objective_section:
          match:
            code:
              coding:
              - {code: 61149-1, system: 'http://loinc.org'}
          schema:
            label: Objective Section
            short: Objective Section
            mustSupport: true
            index: 44
            elements:
              title: {short: title, mustSupport: true, index: 45}
              code:
                label: Objective
                short: Objective
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 61149-1, system: 'http://loinc.org'}
                index: 46
              text: {short: This section contains only human readable content, mustSupport: true, index: 47}
            required: [text, title, code]
        physical_exam_section:
          match:
            code:
              coding:
              - {code: 29545-1, system: 'http://loinc.org'}
          schema:
            label: Physical Exam Section
            short: Physical Exam Section
            mustSupport: true
            index: 48
            elements:
              title: {short: title, mustSupport: true, index: 49}
              code:
                label: Physical findings
                short: Physical findings
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 29545-1, system: 'http://loinc.org'}
                index: 50
              text: {short: text, mustSupport: true, index: 51}
              entry:
                short: entry
                index: 52
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    physical_exam_entry:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/Observation']
                        index: 53
            required: [text, title, code]
        assessment_section:
          match:
            code:
              coding:
              - {code: 51848-0, system: 'http://loinc.org'}
          schema:
            label: Assessment Section
            short: Assessment Section
            mustSupport: true
            index: 2
            elements:
              title: {short: title, mustSupport: true, index: 3}
              code:
                label: Assessments
                short: Assessments
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 51848-0, system: 'http://loinc.org'}
                index: 4
              text: {short: This section contains only human readable content, mustSupport: true, index: 5}
            required: [text, title, code]
        interventions_section:
          match:
            code:
              coding:
              - {code: 62387-6, system: 'http://loinc.org'}
          schema:
            label: Interventions Section
            short: Interventions Section
            mustSupport: true
            index: 26
            elements:
              title: {short: title, mustSupport: true, index: 27}
              code:
                label: Interventions provided
                short: Interventions provided
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: 62387-6, system: 'http://loinc.org'}
                index: 28
              text: {short: text, mustSupport: true, index: 29}
              entry:
                short: entry
                index: 30
                slicing:
                  rules: open
                  discriminator:
                  - {path: resolve(), type: profile}
                  min: null
                  slices:
                    interventions_section:
                      match: {}
                      schema:
                        type: Reference
                        short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                        mustSupport: true
                        refers: ['http://hl7.org/fhir/StructureDefinition/List', 'http://hl7.org/fhir/StructureDefinition/RequestGroup']
                        index: 31
            required: [text, title, code]
package_version: 2.0.0-ballot
class: profile
kind: resource
url: http://hl7.org/fhir/us/ccda/StructureDefinition/Progress-Note
base: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
version: 2.0.0-ballot