Progress Notes
Progress notes should be problem-oriented. The outline below can serve as a guide to the way which they should appear in the chart:
Date
Problem Number
Subjective Data: Symptomatic information belongs here: how the patient feels, historical information.
Objective Data: Physical examination findings, laboratory or test data.
Assessment or Interpretation: In taking into consideration the subjective and objective data, what is your impression of what this all means? Remember that the medical record is an important document–it is important to discuss this section with the resident before recording your assessment in the chart, as your assessment may not be consistent with the opinion of the rest of the ward team.
Plan: This usually follows two general categories:
- Evaluation (additional laboratory studies, procedures, etc)
- Therapy (treatment, educational interventions, etc)
A Progress Note should be written daily. Where rapid changes are occurring, or the patient is extremely ill, several progress notes may be required each day. The Progress Note must be signed by whomever writes it. If the note covers more than one page, each page should be signed.