Progress note

Progress Notes are written by healthcare professionals to document a 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.

The majority of the medical record consists of progress notes documenting the care delivered and the clinical events relevant to diagnosis and treatment for a patient. Progress notes serve as the repository of medical facts and clinical thinking, and are intended as a concise vehicle of communication about a patient’s condition to those who access the health record. 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.

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.

See Also

• Progress Note Software