What Is a Progress Note?

A progress note is an essential tool used in healthcare to document patient information, medical history, treatment plans, and progress throughout a patient’s care. It’s a crucial communication tool among healthcare professionals, ensuring continuity of care and facilitating collaboration.

As physicians, physician assistants, and advanced-practice nurses, your documentation style is as unique as your practice method. However, your documentation compliance and legal requirements are numerous. It is daunting to remember the necessary elements of medical documentation that are clear, concise, medically relevant, meet regulatory guidelines, and improve your patient’s health.

In a study from the American Hospital Association, physicians spent only 27% of their clinic time in face-to-face interactions with patients and the remainder on documentation, care coordination tasks, and coding compliance.

A study in JAMA Internal Medicine documented that only 42% of providers identified the time spent in documentation as appropriate. Interestingly, 58% of those same providers agreed that time spent in documentation interfered with patient care. 

These results reveal the burden placed on providers in documenting the care provided to their patients, making efficient, customizable, and intuitive technology solutions a vital part of medical practice.

TextExpander is a customizable solution that optimizes your progress note documentation, enhances proficiency, and reduces the administrative burden of medical documentation.  To understand how TextExpander works, let’s first examine the purpose and necessary components of progress notes.

See also: Tips for writing medical progress notes faster.

Understanding the basics of progress notes

Documentation is vital to providing quality patient care. Progress notes, in particular, play a crucial role in capturing and communicating important information about a patient’s health status and treatment progress. These notes serve as a written record that captures the details of a patient’s journey, documenting any changes in their condition over time.

Definition of a progress note

A progress note is a written record that captures the details of a patient’s health status, treatment progress, and any changes in their condition over time. It’s a chronological documentation of the patient’s journey and an integral part of the medical record.

Progress notes are written by healthcare professionals, such as doctors, nurses, or therapists directly involved in patient care. These notes provide a comprehensive overview of the patient’s medical history, treatment, and response to interventions.

Importance of progress notes in healthcare

Progress notes are crucial for several reasons such as:

• Comprehensive overview of the medical/surgical history of the patient
• Treatment history
• Treatment response
• Tracking of biometric data points, laboratory, imaging, and other studies
• Benchmarking patient response against standards of care
• Care coordination across the continuum of care

According to the National Committee for Quality Assurance (NCQA), there are 21 specific medication documentation guidelines:

1. Patient identifiers on every page
2. Patient demographic information
3. Entries are electronically or manually signed by the provider
4. Date of documentation
5. Legible content
6. Comprehensive problem list
7. Medications and allergies
8. Past medical/surgical history
9. Social history and use of tobacco, alcohol, or drugs
10. Physical examination and findings
11. Laboratory, imaging, and other studies ordered
12. Diagnoses consistent with physical exam findings
13. Treatment plans aligned with diagnoses and standards of care
14. Instructions for follow-up care and care coordination
15. Unresolved problems and problems to be addressed on subsequent visits
16. Documentation of medical necessity for orders
17. Documentation of consults ordered 
18. Full report of consultation findings, including laboratory, imaging, or other treatments ordered and the outcomes of those treatments
19. Documented risk assessment for patient safety
20. Immunization records
21. Preventive visits per standards of care

Progress notes aid in decision-making and facilitate effective communication and collaboration among healthcare team members. When multiple healthcare professionals are involved in a patient’s care, progress notes share important information, ensuring safe, evidence-based care.

Different types of progress notes

TextExpander is a clever and efficient tool to build customized progress note templates based on best practices and regulatory compliance. By creating TextExpander Snippets, you can create customizable progress note templates. Some examples are:

SOAP notes

SOAP stands for subjective data, objective data, assessment, and plan:

• Subjective: Patient self-reported symptoms
• Objective: Measurable data like vital signs, lab results, physical exams, etc.
• Assessment: Analysis and interpretation of findings used in medical decision-making
• Plan: Plan of care for the current and future health care needs of the patient

Using SOAP notes provides physician efficiency in documentation and ensures that healthcare professionals have a standardized communication and care coordination method.

DAP notes

DAP notes stand for data, assessment, and plan. DAP notes focus on essential data and assessment of the patient’s progress. They rely less on subjective information and emphasize objective observations and measurable outcomes.

Data in DAP notes includes objective information. 

Data:

• Vital signs
• Laboratory results
• Quantifiable data relevant to the patient’s condition 

Assessment:

• Evaluation and interpretation of results
• Comparison of current to previous data to determine outcomes and plan of care

Plan:

• New treatments to address assessment results
• Discharge plans
• Patient educational, emotional, social, and ancillary needs

DAP notes are particularly useful in settings where objective data is crucial for monitoring patient progress, such as rehabilitation centers or research studies. By focusing on measurable outcomes, DAP notes provide a concise and standardized way to track a patient’s improvement over time.

Narrative notes

Unlike SOAP or DAP notes, narrative notes do not follow a specific format or structure. Instead, they provide a comprehensive narrative that tells the patient’s story, including subjective experiences, objective observations, and the healthcare professional’s interpretation. Narrative notes may include details about the patient’s background, social history, or psychosocial factors impacting their progress.

While narrative notes offer more flexibility, they require good documentation skills to ensure clarity and conciseness. Healthcare professionals must balance providing enough detail to convey the patient’s progress and avoiding unnecessary information that may obscure the main points.

Narrative notes are commonly used in mental health settings, where a more holistic understanding of the patient’s experiences and progress is essential. They allow for a comprehensive and individualized approach to documenting patient care.

Efficient charting techniques for doctors and providers

Through the use of TextExpander Snippets, writing concise and informative progress notes is easier than ever. When building your TextExpander Snippets, consider these essential tips: 

• Use clear and concise language to ensure the note’s readability and understandability.
• Include relevant details and observations, avoiding personal opinions or biases.
• Document changes in the patient’s condition accurately and objectively.
• Ensure proper organization and sequencing of information.
• Use appropriate medical terminology and abbreviations.

Common mistakes to avoid

TextExpander can help you avoid these common mistakes:

• Avoid vague or ambiguous language that may lead to misinterpretation.
• Do not include non-essential or unrelated information.
• Avoid copying and pasting previous notes without updating them.
• Avoid using unapproved abbreviations or medical jargon that may confuse others.
• Do not make assumptions or document unverified information.

Creating evidence-based TextExpander Snippets removes the barriers to consistency in medical documentation. Imagine your ability to decrease administrative burden through the use of streamlined medical documentation processes! TextExpander can help you spend more face-to-face time with your patients, improving patient, provider, caregiver, and support staff satisfaction.

Are you ready to revolutionize your documentation process? Join the countless healthcare professionals already benefiting from TextExpander. Take the first step towards efficiency, productivity, and improved patient care. Sign up with TextExpander today and access your FREE 30-day trial. All you have to lose is your frustration.

Becky Zook is a registered nurse with over 30 years of experience in patient care, administration, and executive leadership. Becky is the CEO of a dermatology group and has extensive experience managing remote teams using various tech tools. She also owns NurseWritersGroup, a medical writing and journalism business.