Definitions

For Document Diagram Draft, see https://claude.ai/public/artifacts/669224e8-ae67-4f0a-9282-01f3e2a573f8.

• Consultation Note – Generated by a request from a clinician for an opinion or advice from another clinician. Consultations may involve face-to-face time with the patient or may fall under the auspices of telemedicine visits. Consultations may occur while the patient is inpatient or ambulatory. The Consultation Note should also be used to summarize an Emergency Room or Urgent Care encounter.
• Discharge Summary – A document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge.
• History and Physical Note – A medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
• Operative Note – A frequently used type of procedure note with specific requirements set forth by regulatory agencies. It is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
• Procedure Note – Encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act. It is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient's tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.
• Progress Note – An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note.
• Referral Note – Communicates pertinent information about a provider who is requesting services of another provider of clinical or non-clinical services. The information in this document includes the reason for the referral and additional information that would augment decision making and care delivery.
• Transfer Summary – Standardizes critical information for exchange of information between providers of care when a patient moves between health care settings.

HL7 International. (2026, March 17). Consolidated CDA (C-CDA). https://build.fhir.org/ig/HL7/CDA-ccda/