ARCHETYPE Progress Note (openEHR-EHR-COMPOSITION.progress_note.v0)

ARCHETYPE IDopenEHR-EHR-COMPOSITION.progress_note.v0
ConceptProgress Note
DescriptionDocument used to record details of health-related events that have occurred as part of the subject's care, and/or the subject's health status, findings, opinions and plans that are current at the time of recording.
UseUse to record details of health-related events that have occurred as part of the subject's care, and/or the subject's health status, findings, opinions and plans that are current at the time of recording. Progress notes are more typically used to record ongoing care notes by various providers participating in aspects of care during some kind of healthcare episode, as distinct from a one-off face-to-face meeting in a clinic which is typically recorded as a COMPOSITION.encounter. A progress note may not include a face-to-face meeting between a clinician and the subject, but may be used to record health information remotely from the patient or report on a follow-up telephone conversation or liaison between healthcare providers without the subject present. A typical nursing progress note during a hospital episode might include EVALUATION.reason_for_encounter, EVALUATION.progress_note to record the narrative summary of the nursing shift, a combination of OBSERVATIONS for recording vital signs measurements and/or ACTIONS to record the tasks or procedures carried out.
PurposeTo record details of health-related events that have occurred as part of the subject's care, and/or the subject's health status, findings, opinions and plans that are current at the time of recording.
ReferencesDerived from: Progress note, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2013 Apr 11. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1278_1 (discontinued)
Copyright© Australian Digital Health Agency, openEHR Foundation
AuthorsForfatternavn: Heather Leslie
Organisasjon: Atomica Informatics, Australia
E-post: heather.leslie@atomicainformatics.com
Opprinnelig skrevet dato: 2013-04-11
Other Details LanguageForfatternavn: Heather Leslie
Organisasjon: Atomica Informatics, Australia
E-post: heather.leslie@atomicainformatics.com
Opprinnelig skrevet dato: 2013-04-11
OtherDetails Language Independent{custodian_organisation=openEHR Foundation, references=Derived from: Progress note, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2013 Apr 11. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1278_1 (discontinued), current_contact=Dr Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=39E8BC92B5A362F1CB48E5CD0CB75774, build_uid=dc2721f6-3b42-4994-b7af-252d6e5ad24d, revision=0.0.1-alpha}
Keywordsprogress note
Lifecyclein_development
UIDe5243e9c-8e98-4877-af93-eeee308a2c37
Language useden
Citeable Identifier1078.36.1998
Revision Number0.0.1-alpha
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