Progress notes | definition of progress notes by Medical dictionary [PDF]

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Progress notes | definition of progress notes by Medical dictionary

https://medical-dictionary.thefreedictionary.com/progress+notes

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progress notes



progress notes Etymology: L, progredi + nota, mark (in the patient record) notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned. Progress notes may follow the problem-oriented medical record format. The physician's progress notes usually focus on the medical or therapeutic aspects of the patient's condition and care. The nurse's progress notes, although recording the medical conditions of the patient, usually focus on the objectives stated in the nursing care plan. These objectives may include responses to prescribed treatments, the ability to perform activities of daily living, and acceptance or understanding of a particular condition or treatment. Progress notes in an in-hospital setting are recorded daily; those in a clinic or office setting are usually preceded by an episodic or interval history and are recorded as accounts of each visit. Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.

pro·gress notes

(progres nōts)

Records kept by health care workers to indicate the course of the patient during care. Medical Dictionary for the Health Professions and Nursing © Farlex 2012

progress notes 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. In patients who are not critically ill, a note concerning progress may be made daily or less frequently; for patients in critical care, notes may be made hourly. It is important that each note be clearly written, the date and time recorded, and the note signed. Medical Dictionary, © 2009 Farlex and Partners

progress notes narrative records kept on changes in the animal's condition and treatment administered. In the problem-oriented medical record, it is written in the soap format. Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc. All rights reserved

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