Sample Note

All About Writing Notes & Sample Notes

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Patient Treatment Progress Note

A progress note is used in the medical sector in order to note down or write the progress of a patient after treatment or counseling to a doctor. It is basically a sort of record that is created by nurses or doctors who are caring a particular patient in order to understand the condition of the patient and the effect of medicines and care on the health or recovery of a patient. A progress note has its own format for writing and is usually based on information like the name of the patient, the health issue he/she is suffering from, diagnosis, daily progress, the information about the doctor and nurses who are dealing the patient and the therapy that is used for patient.  A progress note is usually based on a page and the purpose of writing a progress note is just to bring other doctors and nurses to speed and understanding of the health issue and the current situation.

Usually in hospitals, there is a standard printed format with sections in which doctors or nurses have to provide information of the patient about a particular day. The information written in a progress note is based on the interview of the patient. A progress note includes sections like progress of a patient and his/her feeling on that day, a plan section, objective section and an assessment section. Progress notes are filed daily by doctors for patients that have a serious condition.

A Sample Progress Note

8/15/2012

Last two urine tests have been negative for drugs.

No new psychosocial difficulties.  Seemingly spending more time at home and no reports no difficulties at work.

Brief physical shows that his BP continues elevated 152/92.

Reports that he attends NA weekly and continues with the weekly support group (which is confirmed by the group leader.)

Impression

Heroin is used currently in remission.

Participating in a program of recovery and by self-report is used medicines as directed.

Mild blood pressure elevation

Rx Plan

Continue prescribed intake of medicines daily

Return visit 2 weeks

Guidelines to create a progress note

  • Always use the specific form of progress note that is provided by the hospital or is specifically designed for writing and keeping notes.
  • At the top of the note, write the purpose of writing a progress note and current date.
  • For new patients, simply write a brief history of the patient’s condition whereas for older patients it is important to write a brief note about the previous day condition of the patient.
  • Ask a few questions from the patient about his feelings regarding the progress and recovery. Briefly write the interview of the patient. Check the latest report of any test and BP.
  • Write the new progress note in reference to the previous note in a way that clearly compares the progress of the current day with the previous day.
  • Sum up the progress note with your recommendations and thoughts. It is important to add some new prescriptions if necessary.

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