| ARCHETYPE ID | openEHR-EHR-OBSERVATION.progress_note.v1 |
| Concept | Progress note |
| Description | Narrative description of health-related events at a specific point-in-time about an individual, specifically from the perspective of a healthcare provider. |
| Use | Use to manually synthesise and record a narrative description about contemporary health-related events and activities from the perspective of a healthcare provider. This unstructured description may include the subject's health status and findings, that are current at the time of recording. Most commonly this description is likely to be related to nursing notes at the end of a shift, or the daily notes from healthcare providers such as a physician or a physiotherapist. In practice, Progress note is a meta observation that will complement the existing structured clinical record, allowing for expression of subtle, subjective or interpretive information about the patient that might not otherwise be obvious through structured data alone, providing balance and context to the EHR record. In many situations, this archetype will be combined alongside other more structured archetypes within a single COMPOSITION. This archetype may also be used if there are no structured archetypes available, or to record progress notes imported from legacy systems. |
| Misuse | Not to be used to record specific structured or semi-structured health information. For example, detailed information about problems/diagnoses, test results and vital signs, examination findings and patient story/history should be recorded using the specific relevant archetypes EVALUATION or OBSERVATION archetypes. Not to be used to record a narrative, summary view of the patient's health, for example to communicate a succinct summary of the patient's hospital admission as one component of a comprehensive and structured Discharge Summary document. Use the EVALUATION.clinical_synopsis archetype for this purpose. |
| Purpose | To manually synthesise and record a narrative description about health related events that are current at the time of recording, from the perspective of a healthcare provider. |
| References | Derived from: Progress Note, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-11-30]. No longer available. |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2013-04-11 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2013-04-11 |
| OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=Derived from: Progress Note, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-11-30]. No longer available., current_contact=Heather Leslie, Atomica Informatics, heather.leslie@atomicainformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=0DC26E43DE454A2B3FE00A7AEA553E2A, build_uid=715f68b3-8720-4824-aca9-b437ebf5dbba, revision=1.1.1} |
| Keywords | comment, note, progress |
| Lifecycle | published |
| UID | 4c1c083f-70e1-4359-8ea2-07cafca0be0f |
| Language used | en |
| Citeable Identifier | 1013.1.1647 |
| Revision Number | 1.1.1 |
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