100441-5

Attending Outpatient Progress note

Active

Part Description

LP74253-3 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. Source: HL7

LOINC Names Get Info

Fully-Specified Name: Progress note:Find:Pt:Outpatient:Doc:Attending
Long Common Name: Attending Outpatient Progress note
Short Name: Attend OP Prog note

Part Model Get Info

Component
Progress note
LP74253-3
- Analyte
  Progress note
  LP74253-3
  - Component Numerator
    Progress note
    LP74253-3
    - Component Numerator Core
      Progress note
      LP74253-3
    - Component Numerator Core Suffix
      NULL
  - Component Denominator
    NULL
    - Component Denominator Core
      NULL
    - Component Denominator Core Suffix
      NULL
- Challenge
  NULL
- Adjustment
  NULL
- Count
  NULL
Property
Find
LP6813-2
Time
Pt
LP6960-1
- Time Core
  Pt
  LP6960-1
- Time Modifier
  NULL
System
Outpatient
LP32889-5
- System Core
  Outpatient
  LP32889-5
- Super System
  NULL
Scale
Doc
LP32888-7
Method
Attending
LP269960-3

Basic Attributes

Class: DOC.ONTOLOGY
Type: Clinical
First Released: Version 2.73
Last Updated: Version 2.73 (ADD)
Order vs. Observation: Both

Member of these Groups Get Info

LOINC Group	Group Name
LG39003-5	Attending\|ANYTypeOfService\|ANYKindOfNote\|ANYSetting
LG41828-1	Outpatient\|ANYTypeofService\|ANYKindofDocument\|ANYRole\|ANYSubjectMatterDomain
LG38741-1	Progress note\|ANYRole\|ANYSetting

Language Variants Get Info

Tag	Language	Translation
el-GR	Greek (Greece)	Σημείωμα πορείας:Εύρεση:Pt:Εξωτερικός ασθενής:Doc:Θεράπων Synonyms: Doc DOC.ONTOLOGY Pt Εξωτερικός ασθενής Εύρεση Θεράπων Σημείωμα πορείας Σημείωση
it-IT	Italian (Italy)	Progresso, nota:Osservazione:Pt:Paziente esterno:Doc:Assistente Synonyms: Documentazione dell''ontologia Nota di progresso;Nota di miglioramento Osservazione Paziente ambulatoriale;Paziente non ricoverato Punto nel tempo (episodio)
nl-NL	Dutch (Netherlands)	voortgangsrapport:bevinding:moment:poliklinisch:document:behandelend arts Synonyms: poli
zh-CN	Chinese (China)	病程记录:发现:时间点:门诊病人:文档型:主治 Synonyms: 临床文档型;临床文档;文档;文书;医疗文书;临床医疗文书主治（主治医师、主治医生）;主治医师;主治医生发现是一个原子型临床观察指标，并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型，而对于叙述型文本之中所报告的发现，则可能是叙述型。;发现物;所见;结果;结论文档本体;临床文档本体;文档本体;文书本体;医疗文书本体;临床医疗文书本体时刻;随机;随意;瞬间病程（进展、病程进展、病情进展、进展情况、变化情况、发展情况）记录;病程进展记录;病情进展记录笔记;按语;注释;说明;票据;单据;证明书门诊患者

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LOINC Copyright

Copyright © Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://loinc.org/license for the full LOINC copyright and license.