When a patient is admitted in the hospital or a clinic, he is regularly examined by the doctors coming in all shifts. In a well-established clinical setup, doctors are available round the clock and it is their prime duty to keep examining the patients admitted in the hospital.
Usually, the doctors see all the patients of the hospital or a particular ward in every shift. For example, there is a morning round during which doctors, nurses and junior doctors all the staff members visit the patient’s bed by bed and assess the general conditions and address presenting complaints. In the evening shift, when morning doctors leave and the new doctors come to the hospital, they also visit the patients and repeat the process of round and examination. The same thing happens in the night shift.
Patient progress notes
While all the doctors come and examine the patients in their shifts, they document the examination in their files which is called as patient progress notes.
Patient progress notes form
Patient progress notes are generally written by a physician, nurse, physical therapist, social worker or other relevant healthcare professionals that describe the condition of a patient and the planned or given treatment. These notes may be written by following the problem-focused medical record format.
The progress notes prepared by a physician are generally focused on the therapeutic or medical aspects of the patient’s care and condition. On the other hand, the progress notes prepared by a nurse are generally focused on the stated objectives mentioned in the nursing care plan, although the medical condition of the patient is recorded too.
These objectives may be related to different responses to prescribed treatments, understanding or acceptance of a certain treatment or condition, and the ability to perform daily living activities.
In an in-hospital environment, patient progress notes are generally recorded on a daily basis. While in an office or clinic setting, these notes are generally preceded by an interval or episodic history and are documented and recorded on account of each visit.
Patient progress notes usually look like a blank lined paper that is used for patient charts and this blank paper does not contain much content but patient name, date and the notes recorded by a doctor or nurse for documentation.
A progress note is a term traditionally used by a physician to write entries into the medical record of a patient, any other documentation. Some of the other notes written by a physician include admission notes, transfer notes, procedure notes, discharge notes, progress notes sample, nursing progress notes or nursing notes, etc.
Preview and download options
Patient Progress Notes-1
Patient Progress Note-2
Patient Progress Notes-3
Doctors Note Template-1
Microsoft Word File | File size 30 Kb | No. of pages = 2
Doctors Note Template-2
PDF Format File | File size = 41 Kb | No. of pages = 1
Doctors Note Template-3
PDF Format File| File size= 11 KB | No. of pages = 1
Assessment of patient-goals and purpose
Assessment of the patient at each visit is really an integral part of the patient care according to the international standards of healthcare system. Main goal of this assessment is to determine the level of care being provided to the patients, and the treatment standards which the patients are receiving. It also includes making sure that the services provided to the patients are according to their needs and are helpful in improving their health status and health awareness.
Patient’s assessment if done honestly and correctly always results in making better decisions about the future management and treatment needs especially in the emergency cases. This also helps in making a management plan for the elective and planned situations and outcomes are not affected by the changes in patient’s conditions.
According to the JCIA standards, patient’s assessment is always done in a systematic and meticulous way. We never approach the patient in a haphazard and random way. JCIA has formulated proper guidelines while filling the notes during each ward round. These are basically patient progress notes and are written in the format of SOAP.
SOAP is an acronym used for situation, background, assessment, and plan. If we fill the documents in this sequence, we never miss any step while assessing the patient and writing them down in the progress notes.
Let’s discuss how the Soap strategy helps in the best patient progress assessment.
- In the patient progress notes, we always begin with the situation which is active and the presenting complaints of the patient.
- Next is the background in which we mention the history and background of the present situation in brief form.
- Assessment is the third step in which the doctor examines the patient beginning from the general physical examination to the systemic examination.
- At the end of the notes, the doctor writes down the management plan of this particular patient and then duly signs the progress notes to make sure that the orders are carried out properly.