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Daily Progress Notes

The document outlines the components and purpose of a daily progress note, commonly organized using the SOAP format. A progress note serves as a legal medical record of a patient's hospitalization and must be completed daily, documenting subjective and objective findings, patient issues or problems, and an assessment and plan for each problem. Key elements that must be included are the patient's subjective experience since the last note, objective exam findings and test results, an assessment of each problem including differential diagnoses and evidence, and a complete plan to address each problem.

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Muhammad Bilal
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3K views2 pages

Daily Progress Notes

The document outlines the components and purpose of a daily progress note, commonly organized using the SOAP format. A progress note serves as a legal medical record of a patient's hospitalization and must be completed daily, documenting subjective and objective findings, patient issues or problems, and an assessment and plan for each problem. Key elements that must be included are the patient's subjective experience since the last note, objective exam findings and test results, an assessment of each problem including differential diagnoses and evidence, and a complete plan to address each problem.

Uploaded by

Muhammad Bilal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Daily Progress Notes (The SOAP note)

Progress notes are to be written by the resident or intern on each covered medical patient on a daily basis. The
daily progress note serves as a written medical-legal document that:
Serves as a record of a patients hospitalization
Must be completed on a Daily basis and includes all events that occur during the hospitalization
Records events in terms of subjective and objective findings
Must include new and active patient health/social issues (problems)
Each problem is evaluated/assessed and an appropriate plan is formulated
Must be legible and well written so to avoid any misunderstanding by the reader
Must have a time and date and be signed on each page by the author in legible fashion.
The daily progress note is traditionally organized as a SOAP Note. Many, however, organize the Progress
note as HSOAP where the H stands for history and contains one or two sentences summarizing the patients
case.
S=Subjective
Record of subjective findings that occurred during the evening , overnight, and in the morning
that patient is being examed.
Essentially how the patient felt during the evening, night time and morning hours and what
happened during those hours.
O=Objective (Includes all the following)
Physical Exam: Vital signs, focused physical exam but almost always should include:
LUNG
CARDIAC
ABDOMINAL
EXTREMITIES
Laboratory data
Diagnostic Imaging
Microbiology
Please note that a Medication List which includes a listing of all scheduled and PRN (as
needed) medications that are relevant to active problems is always helpful and recommended but
is not required.
A/P=Assessment and Plan:
THIS IS THE MOST IMPORTANT PART OF YOUR NOTE
The Assessment section of the progress note should be organized by problems. (Thus writing a
problem list on the margin of the progress note is helpful in organizing your note but is not
always necessary. Problems must be included in your assessment.)
Assess each problem and include relevant differential diagnosis, evidence suggesting or not
suggesting a diagnosis. It is essentially what do you think caused the problem & why do you
think that.
Once the assessment has been made a plan must be formulated to address each problem (see
below). Plan should be complete and those who read your note should know exactly what you
are doing and why.
Some secondary problems are stable and do not need an assessment but rather just a plan (see
below).
Example Assessment and Plan:
2. Chest Pain: Differential diagnoses remain broad with exact etiology still unclear. Most
concerning at this time remains pericarditis because of the nature of chest pain and EKG
changes. Acute coronary syndrome remains in differential but is less likely given the normal
cardiac enzymes and the nature of the EKG changes. PE is very unlikely given the normal

oxygenation and complete lack of risk factors. Dissection is unlikely as the patient has no
history of HTN and symmetric blood pressures.
If w/u for above life threatening causes negative will further expand differential to include GI,
infectious, musculoskeltal and other causes of chest pain.
Plan:
Serial EKG
Stat ECHO
Follow cardiac enzymes
Morphine for pain control
Continue ASA
Hold Beta Blocker as SBP <100 and HR 60
Consider cardiology consult depending on above workup
2. Mild Anemia: Differential diagnoses includes: decreased production, sequestration,
destruction/loss. At this time most concerning is occult GI blood loss given the patients guaiac
positive stools and microcytic indices.
Plan:
Needs routine health screening (colonoscopy as age recommended).
Check FE studies
Follow serial HCT (check daily)
3. Tobacco abuse: Smoking cessation counseling
4. Code: Full
5. FEN: Cardiac prudent diet
13. Disposition: No plans for D/C within next 24 hours.

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