what is a progress note

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.

“Every keystroke saved, is time saved, which means I can do my job longer and see more children.” — Dr. Melanie Hsu

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

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Subjective:

  • Chief Complaint: “I’ve been experiencing severe back pain for the last three days.”
  • History of Present Illness: The patient is a 45-year-old male reporting lower back pain which started after lifting heavy boxes during a house move. Describes the pain as a constant, dull ache, rating it 7/10 on the pain scale. Notes occasional sharp pains when moving in certain ways.
  • Past Medical History: No prior history of back injuries. No chronic illnesses. No known drug allergies.
  • Social History: Non-smoker, occasional alcohol consumption, works as an accountant.

Objective:

  • Physical Exam: Tenderness noted in the lower lumbar region. No visible swelling or bruising. Pain increases on palpation. Full range of motion is slightly limited due to pain. Neurological examination of the lower extremities is normal.
  • Vital Signs: Blood pressure 130/85, heart rate 78 bpm, temperature 98.6°F, respiratory rate 16 breaths per minute.

Assessment:

  • Primary Diagnosis: Acute lower back pain, likely musculoskeletal in origin, possibly related to strain from heavy lifting.
  • Differential Diagnosis: Herniated disc, kidney stones, or spinal stenosis could be considered but seem less likely given the history and examination.

Plan:

  • Immediate Management: Prescribe NSAIDs for pain management. Advise application of ice and heat alternately on the affected area.
  • Follow-Up: Recommend rest from strenuous activities and gentle stretching exercises. Schedule a follow-up appointment in one week or sooner if symptoms worsen.
  • Referrals and Tests: Consider an X-ray or MRI if no improvement in pain after one week or if symptoms change.
  • Patient Education: Educate on proper lifting techniques and ergonomic adjustments in daily activities to prevent future back injuries.

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.

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Diagnostic:

  • Patient: John Doe, 30-year-old male
  • Date of Session: January 23, 2024
  • Diagnosis: Major Depressive Disorder, moderate, without psychotic features

Assessment:

  • Subjective: John reports feeling “a bit better” than last week. He states that his mood has been low but he’s had some good days. He continues to struggle with sleep irregularities and low motivation, although he mentions that his appetite has improved. John expresses ongoing difficulties with concentration at work.
  • Objective: John appears slightly more engaged in the session today. His eye contact has improved, and he speaks in a more animated tone compared to previous sessions. However, he still exhibits signs of psychomotor retardation and looks fatigued.
  • Mental Status Exam: Dressed in clean clothes, appropriate for the weather. No overt signs of psychosis or immediate risk factors for self-harm or harm to others noted.

Plan:

  • Treatment Plan Updates: Continue current medication regimen. Explore the possibility of adjusting dosages in collaboration with John’s psychiatrist, depending on his progress over the next few weeks.
  • Therapeutic Interventions: Utilized cognitive-behavioral techniques to challenge negative thought patterns and encouraged journaling to track mood fluctuations and identify triggers.
  • Goals: Work on developing healthier sleep habits and increasing daily activity levels. Encourage John to engage in at least one social activity before the next session.
  • Follow-Up: Schedule next session for one week from today. Encourage John to reach out if he experiences any worsening of symptoms or needs additional support.

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.

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Patient: Jane Smith
Date: January 23, 2024
Clinician: Dr. Emily Johnson
Service: Physical Therapy

 

Session Summary:

Jane Smith attended her third physical therapy session for post-operative rehabilitation following a left knee arthroscopy. She arrived on time and was in good spirits, reporting a slight improvement in pain levels since our last meeting. Jane mentioned that she has been diligent with her home exercises, which seems to be aiding her recovery.

During today’s session, we focused on range of motion exercises and began introducing gentle strengthening exercises for the knee. I observed a noticeable improvement in Jane’s ability to perform knee flexion and extension exercises compared to the previous session. However, she still exhibits mild discomfort with certain movements, particularly when performing lateral movements.

We also worked on functional mobility, practicing getting up from a seated position and walking. I noticed Jane’s gait has improved, but she continues to exhibit a mild limp, especially when fatigued. I provided verbal cues to encourage proper weight distribution and knee alignment during these activities.

We discussed the importance of continuing with her home exercise program and avoiding overexertion, which could lead to setbacks in her recovery. I provided Jane with a modified exercise plan to increase the intensity of her workouts gradually. Additionally, we scheduled an extra session next week to monitor her progress more closely and make any necessary adjustments to her treatment plan.

Jane tolerated today’s session well and left the clinic reporting a high level of satisfaction with her progress so far. She remains motivated and compliant with her treatment plan, which is positively impacting her recovery trajectory.

 

Plan for Next Session:

  • Continue to progress with range of motion and strengthening exercises.
  • Focus on improving gait and reducing limp during ambulation.
  • Monitor response to the new exercise regimen and adjust as needed.

Additional Notes:

  • Monitor for signs of overexertion or knee swelling.
  • Consider referring to a specialist if there is no continued improvement in lateral movement discomfort.

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.