A progress note is a type of medical record produced by nurses or doctors caring 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 therapeutic strategy, and the patient's most recent test results. The typical progress note is usually no more than one page long and does not generally contain detailed background information about the patient's condition. It is instead normally intended to bring other nurses and doctors up to speed on the progress of the patient's condition.
Most medical professionals write their progress notes in a standardized format broken into sections by topic. This format is called the Subjective, Objective, Assessment 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 therapeutic strategy they think best. Most professionals don't feel it's necessary to describe why they've chosen that plan. Some will go into a more detailed explanation if they feel their reasons may not make sense to their colleagues.
In the assessment section of the note, the doctor or nurse will record his opinion of the patient's current diagnosis. There will also usually be a brief statement on the progress of the condition, whether it remains stable, seems to be getting worse, or seems to be getting better. In the objective section of the progress note, most nurses and doctors will record the results of any medical tests that have come back since the last progress note was filed.
Progress notes may be filed daily if the patient's condition is severe. In any case, such a note is usually filed when the patient is received, when he is released, or if he dies in the hospital. They will also usually be filed if the patient experiences an emergency episode, undergoes a procedure or surgery, or is transferred to another unit. A new progress note will almost always be written up if the patient's symptoms change or if new symptoms develop.
