Idea Transcript
page sections introduction identification subjective objective assessment and plan resources and references
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. return to top
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. return to top
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). return to top
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. return to top
Resources and References Writing an Effective Progress Note - University of Florida Medical University of South Carolina - example SOAP notes return to top Sharing In Health is for training in careers with inherent risks; consult with a health care professional before making any decision. We cannot be held responsible for adverse events of any kind. Please forgive and contact us regarding errors. Feel free to use and share this material as widely as possible, according to our Creative Commons license.