ARCHETYPE Progress note (openEHR-EHR-OBSERVATION.progress_note.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.progress_note.v1
ConceptProgress note
DescriptionNarrative description of health-related events at a specific point-in-time about an individual, specifically from the perspective of a healthcare provider.
UseUse 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 physioterapist. 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.
MisuseNot to be used to record specific structured or semistructured 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.
PurposeTo 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.
ReferencesDerived from: Progress Note, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-11-30]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1322
Copyright© National E-Health Transition Authority, openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-04-11
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-04-11
OtherDetails Language Independent{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]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1322, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=002FCDA81D5C873D27DEEF9AEEA1197C, build_uid=669b2dc5-1612-486c-b3ca-6b5fb9e8da14, revision=1.0.1}
Keywordscomment, note, progress
Lifecyclepublished
UID4c1c083f-70e1-4359-8ea2-07cafca0be0f
Language useden
Citeable Identifier1013.1.1647
Revision Number1.0.1
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Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
SB Bhattacharyya, Sudisa Consultancy Services, India
Simon Chapman, King's College Hospital, United Kingdom
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Stig Erik Hegrestad, Helse Førde, Norway
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)
Heather Grain, Llewelyn Grain Informatics, Australia
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Hilde Hollås, DIPS AS, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Lars Ivar Mehlum, Helse Bergen HF, Norway
Heather Leslie, Ocean Health Systems, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Lars Morgan Karlsen, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Phuong Pedersen, DIPS, Norway
Vladimir Pizzo, Hospital Sírio Libanês, Brazil
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Gro-Hilde Ulriksen, Norwegian center for ehealthresearch, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor), originalLanguage=en, translators=Norwegian Bokmål: Vebjørn Arntzen, Oslo universitetssykehus HF, Norway
Spanish (Argentina): Alan March, Hospital Universitario Austral, amarch@cas.austral.edu.ar, MD
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