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: <Add reference to original resource here>
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)
Copyright© Australian Digital Health Agency, openEHR Foundation, HiGHmed
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2013-04-11
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2013-04-11
OtherDetails Language Independent{custodian_organisation=HiGHmed, references=Derived from: 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.highmed, original_publisher=HiGHmed, custodian_namespace=org.highmed, MD5-CAM-1.0.1=ECE26B9B4D23577F3278A2AB4A5A841F, build_uid=8a6caeea-8737-442d-af99-772fffe755bd, revision=0.0.1-alpha}
Keywordsprogress note
Lifecyclein_development
UIDa0ec545a-723c-4ed2-b372-95fa8ca8290b
Language useden
Citeable Identifier1246.145.889
Revision Number0.0.1-alpha
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