Progress note
Progress Notes are written in the chart to document the patient's status or achievements in aspects of treatment and discharge. Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Most progress notes are written in the format of a SOAP note. The term “SOAP notes” refers to a particular format of recording information regarding treatment procedures. Documentation of treatment is an extremely important part of the treatment process. In virtually all forms of business, some form of documentation is required and SOAP notes are the most popular format in a medical settings. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
Physician 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 bases, depending on the level of critical care notes may be requied anywhere from several times an hour to several times a day.