Progress note

From WikiMD's Wellness Encyclopedia

A progress note is a documentation of the healthcare provider's observations and assessments of a patient's condition and treatment during a specific encounter. It serves as a crucial communication tool among healthcare professionals and is an essential part of the patient's medical record. Progress notes are typically written in a structured format to ensure clarity and consistency in the documentation of patient care.

Structure of a Progress Note[edit | edit source]

A typical progress note includes the following components:

1. Subjective: This section includes the patient's self-reported symptoms, concerns, and any information provided by the patient or their family.

2. Objective: This section contains the healthcare provider's observations, physical examination findings, test results, and other measurable data related to the patient's condition.

3. Assessment: In this section, the healthcare provider summarizes the patient's current diagnosis, progress, and any changes in their condition.

4. Plan: The plan outlines the next steps in the patient's treatment, including medications, procedures, referrals, and follow-up appointments.

Importance of Progress Notes[edit | edit source]

Progress notes play a vital role in ensuring continuity of care for patients. They provide a comprehensive overview of the patient's medical history, current status, and treatment plan. Progress notes also serve as a legal document that can be used to track the patient's progress over time and justify the care provided.

Types of Progress Notes[edit | edit source]

There are several types of progress notes used in healthcare settings, including:

  • SOAP Note: Subjective, Objective, Assessment, Plan
  • DAR Note: Data, Assessment, Response
  • PIE Note: Problem, Intervention, Evaluation

Each type of progress note has its own format and structure, but they all aim to document the patient's care accurately and effectively.

Example of a Progress Note[edit | edit source]

Subjective[edit | edit source]

The patient reports feeling fatigued and experiencing shortness of breath with minimal exertion.

Objective[edit | edit source]

Vital signs: BP 120/80, HR 80, RR 18, Temp 98.6°F Physical exam: Clear lung sounds, no edema noted

Assessment[edit | edit source]

1. Diagnosis: Hypertension 2. Plan: Increase dose of antihypertensive medication, schedule follow-up in two weeks

Related Pages[edit | edit source]


Contributors: Prab R. Tumpati, MD