Progress Notes are the part of a

medical record The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdic ...

where healthcare professionals record details to document a

patient A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other hea ...

's clinical status or achievements during the course of a hospitalization or over the course of

outpatient care Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and proce ...

. Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the

SOAP note The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenti ...

, where the note is organized into Subjective, Objective, Assessment, and Plan sections. Another example is the DART system, organized into Description, Assessment, Response, and Treatment. Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both

physician A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...

s and

nurse Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health c ...

s to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other members of the medical care team, and allow retrospective review of case details for a variety of interested parties. They are the repository of medical facts and clinical thinking, and are intended to be a concise vehicle of communication about a patient’s condition to those who access the health record. The majority of the medical record consists of progress notes documenting the care delivered and the clinical events relevant to

diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...

and treatment for a patient. They should be readable, easily understood, complete, accurate, and concise. They must also be flexible enough to logically convey to others what happened during an encounter, e.g., the chain of events during the visit, as well as guaranteeing full accountability for documented material, e.g., who recorded the information and when it was recorded. L. Weed: "The Problem Oriented Record as a Basic Tool in Medical Education, Patient Care, and Research." Ann. Clin. Res., 1971, 3, (3). Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be required anywhere from several times an hour to several times a day.

Noise in Progress Notes

The urge amongst clinicians for faster text entry while attempting to retain semantic clarity has contributed to the noisy structure of progress notes. A progress note is considered as containing noise when there is difference between the surface form of the entered text and the intended content. For instance, when a clinician enters "bp" instead of "blood pressure", or an acronym such as "ARF" that could mean "Acute Renal Failure" or "Acute Rheumatic Fever". The more noise clinicians introduce in their progress notes, the less intelligible the notes will become. Some of the common types of noise are abbreviation, misspelling and punctuation errors.

References

{{DEFAULTSORT:Progress Note Health care