A progress note is a medical record written by nurses or physicians in a specific format, usually containing information about the patient’s progress, diagnosis, treatment plan, and test results. The standard format is SOAP, with sections for subjective, objective, evaluation, and plan. Progress notes are archived when the patient’s condition is serious, discharged, or transferred, and new notes are written if symptoms change.
A progress note is a type of medical record produced by nurses or physicians who care for patients in clinical settings. This type of medical record is usually written in a specific format. The progress note typically contains information about the patient’s daily progress, the patient’s current diagnosis, the doctor’s or nurse’s intended treatment strategy, and the patient’s most recent test results. The typical progress note is usually no more than one page long and generally does not contain detailed background information about the patient’s condition. Normally, however, the intention is to inform other nurses and doctors about the progress of the patient’s condition.
Most medical professionals write progress notes in a standard format divided into sections by topic. This format is called Subjective, Objective, Evaluation and Plan (SOAP). The first section usually includes information about how the patient is feeling that day and any changes in the patient’s condition that have occurred since the last progress note was filed. This information is usually gathered by interviewing the patient.
In the plan section of the progress note, most medical professionals will describe the treatment strategy they feel is best. Most professionals don’t find it necessary to describe why they chose that plan. Some will go into a more detailed explanation if they feel their reasons might not make sense to their colleagues.
In the evaluation section of the note, the doctor or nurse will record their opinion of the patient’s current diagnosis. There will usually also be a brief statement of how the condition is progressing, whether it remains stable, seems to be getting worse or seems to be improving. In the objective section of the progress note, most nurses and doctors will record the results of any medical tests that have returned since the last progress note.
Progress notes can be archived daily if the patient’s condition is serious. In any case, such a note is usually filed when the patient is received, when he is discharged or if he dies in hospital. They are also usually archived if the patient has an emergency episode, undergoes a procedure or surgery, or is transferred to another unit. A new progress note will almost always be written if the patient’s symptoms change or if new symptoms develop.
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