archetype (adl_version=1.4; uid=4c1c083f-70e1-4359-8ea2-07cafca0be0f)
	openEHR-EHR-OBSERVATION.progress_note.v1

concept
	[at0000]	-- Progress note
language
	original_language = <[ISO_639-1::en]>
	translations = <
		["de"] = <
			language = <[ISO_639-1::de]>
			author = <
				["name"] = <"Natalia Strauch">
				["organisation"] = <"Medizinische Hochschule Hannover">
				["email"] = <"Strauch.Natalia@mh-hannover.de">
			>
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			author = <
				["name"] = <"Vebjørn Arntzen">
				["organisation"] = <"Oslo universitetssykehus HF, Norway, Oslo University Hospital">
				["email"] = <"varntzen@ous-hf.no">
			>
		>
		["es-ar"] = <
			language = <[ISO_639-1::es-ar]>
			author = <
				["name"] = <"Alan March">
				["organisation"] = <"Hospital Universitario Austral">
				["email"] = <"amarch@cas.austral.edu.ar">
			>
			accreditation = <"MD">
		>
		["nl"] = <
			language = <[ISO_639-1::nl]>
			author = <
				["name"] = <"Joost Holslag">
				["organisation"] = <"Nedap">
				["email"] = <"joost.holslag@nedap.com">
			>
			accreditation = <"MD">
		>
	>
description
	original_author = <
		["name"] = <"Heather Leslie">
		["organisation"] = <"Atomica Informatics">
		["email"] = <"heather.leslie@atomicainformatics.com">
		["date"] = <"2013-04-11">
	>
	details = <
		["de"] = <
			language = <[ISO_639-1::de]>
			purpose = <"Zur Repräsentation eines manuellen Zusammenfassen von gesundheitsbezogenen Ereignissen, die aus Sicht eines Gesundheitsdienstleisters zum Zeitpunkt der Aufzeichnung aktuell sind.">
			use = <"Verwenden Sie diesen Archetyp, um eine Beschreibung über aktuelle gesundheitsbezogene Ereignisse und Aktivitäten aus der Sicht eines Gesundheitsdienstleisters manuell zu synthetisieren und aufzuzeichnen. 

Diese unstrukturierte Beschreibung kann den Gesundheitszustand und die Befunde des Patienten enthalten, die zum Zeitpunkt der Aufzeichnung aktuell sind. Am häufigsten bezieht sich diese Beschreibung wahrscheinlich auf Notizen zur Krankenpflege am Ende einer Schicht oder auf die täglichen Notizen von Gesundheitsdienstleistern wie einem Arzt oder einem Physiotherapeuten. In der Praxis ist Fortschrittbericht eine Meta-Beobachtung, die die vorhandene strukturierte Patientenakte ergänzt und es ermöglicht, subtile, subjektive oder interpretative Informationen über den Patienten auszudrücken, die ansonsten möglicherweise nicht allein durch strukturierte Daten offensichtlich sind, und der EHR-Aufzeichnung Ausgewogenheit und Sinnzusammenhang verleiht. In vielen Situationen wird dieser Archetyp zusammen mit anderen strukturierteren Archetypen in einer einzigen COMPOSITION zusammengefasst. 

Dieser Archetyp kann auch verwendet werden, wenn keine strukturierten Archetypen verfügbar sind oder um Fortschrittberichte aufzuzeichnen, die aus alten Systemen importiert wurden.">
			keywords = <"Kommentar", "Notiz", "Anmerkung", "Fortschritt", "Ablauf">
			misuse = <"Nicht zur Repräsentation bestimmter strukturierter oder semistrukturierter Gesundheitsinformationen verwenden. Beispielsweise sollten detaillierte Informationen zu Problemen / Diagnosen, Testergebnissen und Vitalzeichen, Untersuchungsergebnissen und Patientengeschichte / -anamnese unter Verwendung der spezifischen relevanten EVALUATION- oder OBSERVATION-Archetypen dargestellt werden.

Darf nicht verwendet werden, um eine beschreibende, zusammenfassende Ansicht des Gesundheitszustands des Patienten darzustellen, beispielsweise um eine kurze Zusammenfassung der stationären Aufnahme des Patienten als Bestandteil eines umfassenden und strukturierten Entlassungsberichtes zu übermitteln. Verwenden Sie zu diesem Zweck den Archetyp EVALUATION.clinical_synopsis.">
			copyright = <"© openEHR Foundation">
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			purpose = <"For at helsepersonell skal kunne lage og lagre en oppsummering i fritekst om helserelaterte hendelser eller status som er gyldig på tidspunktet det registreres.">
			use = <"Brukes for at helsepersonell skal kunne lage en oppsummering i fritekst om helserelaterte hendelser eller status som er gyldig på tidspunktet det registreres. Denne ustrukturerte beskrivelsen kan inkludere individets helsestatus og funn som er gyldige på registreringstidspunktet. Dette kan sammenlignes med et fritekst journalnotat, som et sykepleiernotat ved vaktskifte, eller et daglig notat fra lege, fysioterapeut eller annet helsepersonell. I praksis vil \"Tidfestet fritekst\" være observasjoner på overordnet nivå som vil komplettere eksisterende strukturert informasjon, og dermed tillate mer subtile, subjektive eller tolkende informasjon om et individ. Det vil være naturlig å kombinere denne arketypen med strukturerte arketyper i en COMPOSITION.

Arketypen kan også benyttes når det ikke finnes strukturerte arketyper tilgjengelig, eller til å lagre journaltekst som blir konvertert fra et annet journalsystem.">
			keywords = <"kommentar", "notat", "løpende">
			misuse = <"Skal ikke brukes for å registrere spesifikk strukturert eller semistrukturert helseinformasjon, for eksempel detaljert informasjon om problem/diagnose, laboratoriesvar og vitale tegn, undersøkelsesfunn og anamneseinformasjon. Denne type data skal registreres i de spesifikke relevante EVALUATION- eller OBSERVATION-arketypene.

Brukes ikke for registrere en fritekstoppsummering av en pasients helse, for eksempel for å gi en konkret oppsummering av en sykehusinnleggelse som en del av en strukturert epikrise eller en sykepleiesammenfatning. Bruk arketypen EVALUATION.clinical_synopsis (Klinisk sammendrag) for dette formålet.">
			copyright = <"© openEHR Foundation">
		>
		["es-ar"] = <
			language = <[ISO_639-1::es-ar]>
			purpose = <"Para la síntesis y registro manuales de la descripción narrativa de eventos actuales relacionados con la salud, desde la perspectiva del proveedor de cuidados de la salud.">
			use = <"utilizado para la síntesis y registro manuales de la descripción narrativa de eventos y actividades actuales relacionados con la salud, desde la perspectiva del proveedor de cuidados de la salud.
Esta descripción no estructurada puede incluir el estado de salud y hallazgos propios del sujeto que corresponden al momento del registro. El caso mas común probablemente se relacione con las notas de enfermería al final de un turno o las notas diarias del proveedor de cuidados de la salud, como es el caso de un médico o un fisioterapeuta. En la práctica, la Nota de Evolución es una meta observación que complementará el registro estructurado, permitiendo la expresión de información sutil, subjetiva o interpretativa acerca del paciente que de otro modo podría no resultar obvia a partir de los datos estructurados solamente, proveyendo así balance y contexto al registro clínico. En muchas situaciones, este arquetipo puede usarse en combinación con otros arquetipos mas estructurados dentro de una misma COMPOSITION.

Este arquetipo también puede ser utilizado si no existe un arquetipo estructurado disponible para un dato determinado, o para importar notas de evolución de sistemas legados.">
			keywords = <"comentario", "nota", "evolución">
			misuse = <"No debe utilizarse para registrar información específica de salud estructurada o semiestructurada. Por ejemplo, la información detallada acerca de problemas o diagnósticos, resultados de exámenes y signos vitales, hallazgos del examen y la enfermedad actual descrita por el paciente deben ser registrada utilizando los arquetipos específicos relevantes del tipo EVALUATION u OBSERVATION.">
			copyright = <"© openEHR Foundation">
		>
		["en"] = <
			language = <[ISO_639-1::en]>
			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.">
			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.">
			keywords = <"comment", "note", "progress">
			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.">
			copyright = <"© openEHR Foundation">
		>
		["nl"] = <
			language = <[ISO_639-1::nl]>
			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.(en)">
			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 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.(en)">
			keywords = <"*comment(en)", "*note(en)", "*progress(en)">
			misuse = <"*Not 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.(en)">
			copyright = <"© openEHR Foundation">
		>
	>
	lifecycle_state = <"published">
	other_contributors = <"Tomas Alme, Norway", "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)">
	other_details = <
		["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">
	>

definition
	OBSERVATION[at0000] matches {    -- Progress note
		data matches {
			HISTORY[at0001] matches {    -- Event Series
				events cardinality matches {1..*; unordered} matches {
					EVENT[at0002] occurrences matches {0..*} matches {    -- Any event
						data matches {
							ITEM_TREE[at0003] matches {    -- Tree
								items cardinality matches {0..*; unordered} matches {
									ELEMENT[at0004] occurrences matches {0..1} matches {    -- Progress Note
										value matches {
											DV_TEXT matches {*}
										}
									}
								}
							}
						}
					}
				}
			}
		}
		protocol matches {
			ITEM_TREE[at0005] matches {    -- Tree
				items cardinality matches {0..*; unordered} matches {
					allow_archetype CLUSTER[at0006] occurrences matches {0..*} matches {    -- Extension
						include
							archetype_id/value matches {/.*/}
					}
				}
			}
		}
	}


ontology
	term_definitions = <
		["en"] = <
			items = <
				["at0000"] = <
					text = <"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.">
				>
				["at0001"] = <
					text = <"Event Series">
					description = <"@ internal @">
				>
				["at0002"] = <
					text = <"Any event">
					description = <"Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.">
				>
				["at0003"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0004"] = <
					text = <"Progress Note">
					description = <"Narrative description of health-related events, health status, findings, opinions at a specific point-in-time.">
				>
				["at0005"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0006"] = <
					text = <"Extension">
					description = <"Additional information required to extend the model with local content or to align with other reference models or formalisms.">
					comment = <"For example: local information requirements; or additional metadata to align with FHIR.">
				>
			>
		>
		["nb"] = <
			items = <
				["at0000"] = <
					text = <"Tidfestet fritekst">
					description = <"Fritekstbeskrivelse av et individs helserelaterte hendelser på et spesifikt tidspunkt, sett fra helsepersonellets synsvinkel.">
				>
				["at0001"] = <
					text = <"Event Series">
					description = <"@ internal @">
				>
				["at0002"] = <
					text = <"Uspesifisert hendelse">
					description = <"Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i en template eller i en applikasjon.">
				>
				["at0003"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0004"] = <
					text = <"Tidfestet fritekst">
					description = <"Fritekstbeskrivelse av helserelaterte hendelser, status, funn eller oppfatninger på et spesifikt tidspunkt.">
				>
				["at0005"] = <
					text = <"*Tree(en)">
					description = <"*@ internal @(en)">
				>
				["at0006"] = <
					text = <"Tilleggsinformasjon">
					description = <"Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer.">
					comment = <"For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR.">
				>
			>
		>
		["es-ar"] = <
			items = <
				["at0000"] = <
					text = <"Nota de evolución">
					description = <"Descripción narrativa de un evento relacionado con la salud para un paciente en un punto especificado del tiempo y desde la perspectiva del proveedor de cuidados de la salud.">
				>
				["at0001"] = <
					text = <"Event Series">
					description = <"@ internal @">
				>
				["at0002"] = <
					text = <"Cualquier evento">
					description = <"Punto en el tiempo o intervalo no especificado que puede ser explícitamente definido en una plantilla o en tiempo de ejecución.">
				>
				["at0003"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0004"] = <
					text = <"Nota de evolución">
					description = <"Descripción narrativa de eventos relacionados con la salud, estado de salud, hallazgos u opiniones para un punto específico en el tiempo.">
				>
				["at0005"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0006"] = <
					text = <"Extensión">
					description = <"Información adicional requerida para el registro de contenidos locales o para el alineamiento con otros modelos o formalismos.">
					comment = <"Por ejemplo: requerimientos de información local o metadatos adicionales para el alineamiento con equivalentes de FHIR o CIMI.">
				>
			>
		>
		["nl"] = <
			items = <
				["at0006"] = <
					text = <"*Extension(en)">
					description = <"*Additional information required to capture local content or to align with other reference models/formalisms.(en)">
					comment = <"*For example: Local information requirements or additional metadata to align with FHIR or CIMI equivalents.(en)">
				>
				["at0005"] = <
					text = <"*Tree(en)">
					description = <"*@ internal @(en)">
				>
				["at0004"] = <
					text = <"Beloopsnotitie">
					description = <"Verhalende beschrijving van gezondheids gebeurtenissen op een specifiek moment in de tijd over een individu, specifiek vanuit het perspectief van een zorgvelener.">
				>
				["at0003"] = <
					text = <"*Tree(en)">
					description = <"*@ internal @(en)">
				>
				["at0002"] = <
					text = <"*Any event(en)">
					description = <"*Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.(en)">
				>
				["at0001"] = <
					text = <"*Event Series(en)">
					description = <"*@ internal @(en)">
				>
				["at0000"] = <
					text = <"Beloopsnotitie">
					description = <"Verhalende beschrijving van gezondheids gebeurtenissen op een specifiek moment in de tijd over een individu, specifiek vanuit het perspectief van een zorgvelener.">
				>
			>
		>
		["de"] = <
			items = <
				["at0000"] = <
					text = <"Fortschrittbericht">
					description = <"Einfache Beschreibung von gesundheitsbezogenen Ereignissen zu einem bestimmten Zeitpunkt über eine Person, insbesondere aus der Sicht eines Gesundheitsdienstleisters.">
				>
				["at0001"] = <
					text = <"Event Series">
					description = <"@ internal @">
				>
				["at0002"] = <
					text = <"Beliebiges Ereignis">
					description = <"Standardwert, ein undefinierter/s Zeitpunkt oder Intervallereignis, das explizit im Template oder zur Laufzeit der Anwendung definiert werden kann.">
				>
				["at0003"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0004"] = <
					text = <"Fortschrittbericht">
					description = <"Einfache Beschreibung von gesundheitsbezogenen Ereignissen, Gesundheitszustand, Befunden, Meinungen zu einem bestimmten Zeitpunkt.">
				>
				["at0005"] = <
					text = <"Tree">
					description = <"@ internal @">
				>
				["at0006"] = <
					text = <"Erweiterung">
					description = <"Zusätzliche Informationen zur Erfassung lokaler Inhalte oder Anpassung an andere Referenzmodelle/Formalismen.">
					comment = <"Zum Beispiel: Lokaler Informationsbedarf oder zusätzliche Metadaten zur Anpassung an FHIR-Ressourcen oder CIMI-Modelle.">
				>
			>
		>
	>