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Outline Prog Note

The document provides an outline for writing a progress note, including recommended sections and content. Progress notes should be one page or less and include key events from the last 24 hours, subjective and objective patient information like vital signs and exam findings, a medication list, assessment of problems, and plans for the day. Feedback should be requested to improve note writing skills. Different clinical rotations may have preferred note formats, so clerks should ask residents and attendings for guidance.

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Setya Gon Freccss
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201 views

Outline Prog Note

The document provides an outline for writing a progress note, including recommended sections and content. Progress notes should be one page or less and include key events from the last 24 hours, subjective and objective patient information like vital signs and exam findings, a medication list, assessment of problems, and plans for the day. Feedback should be requested to improve note writing skills. Different clinical rotations may have preferred note formats, so clerks should ask residents and attendings for guidance.

Uploaded by

Setya Gon Freccss
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Outline for Writing a Progress Note

Debra Bynum and Christopher Klipstein

While in general the format for progress notes will be the same, each clerkship will have
somewhat different styles for their standard progress notes. Look in the student Sherpa
guide for some examples of progress notes from each clerkship. Ask your residents and
attendings what is expected. Remember to be flexible. Accept that different residents and
attendings will expect something different.
Ask for feedback. Ask again until you get constructive feedback. Incorporate this feedback.
Perfect practice makes perfect.
To begin:
1.
2.
3.
4.
5.

If writing by hand, please write legibly


Length should be 1 page
Label note: Medical Student Progress Note
Include Date, Time Written, Hospital Day #
When using WebCIS at UNC, some of this happens automatically

Sections of Progress notes:


1.

Events of last 24 hours (some put this info here, others in the Objective section)
a. Comment on significant changes in clinical status (e.g., became febrile or hypoxic)
b. Report on important treatment interventions undertaken and their effect
c.

Review major new input from consulting services

d. Note results of major studies that led to changes in management


2.

Subjective
a. Describe any new complaints. Common things to ask most patients about include
shortness of breath, chest pain, pain anywhere, bowel movements, urination,
nausea/vomiting, sleep
b. Report presence/absence of symptoms relevant for individual clerkships (e.g.,
surgery: bowel movements, pain, wounds; psych: mood, suicidal thoughts, etc.)
c.

Report presence/absence of symptoms related to the major problems on problem


list (e.g., if CHF is near top of list, need to ask about SOB, orthopnea, PND and
edema)

d. Follow-up on previously mentioned complaints (e.g., if had diarrhea yesterday, need


to report on this today)

e. Omit non-essential complaints (e.g., if your patient is upset that his TV is broken,
mention this to the appropriate person outside of rounds to help address the problem
- this does not need to be written in progress note)
3.

Objective
a. Physical exam
i. List vital signs (give ranges when appropriate, T max and current, include
ins/outs)
ii. Describe general appearance
iii. Report standard physical exam from that morning. Ask during each clerkship
what should be included in a standard follow-up exam.
iv. Emphasize presence/absence of specific exam findings pertinent to major items
on problem list (e.g., if CHF is near top of list, need to comment on JVD, crackles,
gallops, edema)
b. Labs / Studies
i. List all lab and study results. Highlight those that result in changes in
management.
ii. Start with basic labs first. CBC chem 10 LFTs coags other blood labs
urine EKG CXR major studies (radiology or biopsy results)
c.

4.

Events of last 24 hours (if not listed as first part of note above)

Medication list (from Medication Administration Record)


a. Include complete, up-to-date list
b. Include planned finish date for relevant meds (e.g., day 4/10 of vancomycin)
c. Include frequency of use for important as needed medications (e.g., list how much
pain medication a patient required)

5.

Summary statement as first line of Assessment


a. Name, Age
b. Reason for admission and/or state the working diagnosis if known for major items
on problem list

6.

Assessment
a. Some like to have separate Assessment and Plans sections while others like to link
assessment and plan together for each problem on the list
b. Organize by problem list, not by organs/systems (e.g., pneumonia instead of
pulmonary)
c.

Start with the currently most important problem first and report in order of
decreasing importance (order of list might change from day to day)

d. Use most specific label you can for each problem


e. Assess and synthesize, do not just summarize. Demonstrate your thinking of the
differential diagnosis and the clinical approach to the major problems
f.

7.

Include the status of each problem (improving, deteriorating, stable)

Plans
a. Make an actual plan for the day. Do not just make an assessment and then look for
help generating a plan on rounds.
b. Include work-up and treatment plans based upon differential diagnosis of each
problem.
c.

Review your plans with your intern/resident so that you have the most up-to-date
information and can create plans that will be considered reasonable.

d. Include Social Work needs / Discharge planning as last problem on list.


8.

Sign note
a. If handwriting, also print name next to signature.
b. If have pager, include pager number as well.

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