Progress Notes
last authored: Nov 2011, David LaPierre
last reviewed: Nov 2011, Marguerite Miller
Introduction
A progress note serves a number of critical functions. It tracks patient progress, communicates to other health care providers what you are thinking and doing, it allows you to refer back to your assessment and plan, it allows for effective creation of discharge summary, and it provides a medico-legal record if this unfortunate situation arises.
A progress note be written each time the patient is seen i.e. daily rounds or more than once per day if the patient's condition changes (this allows for other health care providers to be aware the patient's condition was acknowledged).
WRITE LEGIBLY, and always date/time and sign the note. This is a legal document, carrying important responsibility.
As learners begin to write progress notes, it is critical to follow an established format. While different services and staff have different approaches, the following is a largely universal approach.
Identification
Start with saying who YOU are. Follow with a 1-3 line summary of the patient. Include patient age, date of admission, admission diagnosis, and pertinent past medical history.
Subjective
Focus on the symptoms the patient has had since presentation; document any new symptoms and review events since the previous note. It can be helpful to use the patient's own words to describe what they have been experiencing.
Objective
Transcribe vitals, relevant labs, and diagnostic results.
You do not need to record a full physical exam; rather, focus on relevant details.
It may be appropriate to track fluid status (ins and outs).
Assessment and Plan
It is often helpful to combine A/P together.
Begin with a one-sentence summary of the patient, including age, length of admission, key diagnoses, clinical condition, and outstanding tasks.
Follow this with a problem list. Introduce each diagnosis, symptom, or indicator of clinical status. For each problem, come provide relevant information, concerns, and plan.
It is helpful to consider each system when creating a problem list. Include (where relevant):
- cardiovascular
- respiratory
- renal and fluids
- neurological
- gastrointestinal
- genitourinary
- endocrine
- musculoskeletal
- hematology
- infection/wounds
- psychosocial
- other lab results
End with disposition: how long they'll be in hospital, followup plan, and steps required to reach this goal.
Resources and References
Writing an Effective Progress Note - University of Florida
Medical University of South Carolina - example SOAP notes
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