How to Write Inpatient Progress Notes with Templates

Updated: April 25, 2024

For seasoned healthcare professionals, efficient documentation is key to managing patient care and workflow in hospital settings. This guide offers insights into streamlining the process of writing inpatient progress notes.

Let’s cover the essentials of crafting effective notes, the advantages of using templates, and how TextExpander can transform your note-taking into a more streamlined, effective practice.

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What are Inpatient Progress Notes?

Inpatient progress notes are vital records that track the status and changes of the patient’s condition during their hospital stay. As a doctor, nurse, or other healthcare provider, these notes are your daily entries cataloging treatments, observations, and plans. These serve as a legal document and critical communication tools among the various caregivers involved in a patient’s care.

How to Write Effective Inpatient Progress Notes

Writing effective progress notes is key to efficient patient management and communication. Here are some things to keep in mind as you write your notes:

  • Be Concise: Get to the point quickly. Use bullet points to break up complex information.
  • Stay Organized: Structure your notes with headers and consistent formatting to make critical information easy to find.
  • Include Pertinent Information: Always note the date, time, and your identification. Record patient observations, medical decisions made, and the rationale for each decision.
  • Use Standardized Language: Employ common medical abbreviations and terminology to ensure clarity and readability.

Benefits of Using Inpatient Progress Notes Templates

Templates can drastically improve the efficiency and accuracy of your documentation. They ensure that all of the patient’s necessary information is included, reducing the risk of omissions. Templates also standardize the records across different staff and shifts, which can enhance the consistency of patient care.

How TextExpander Can Help

TextExpander expedites the documentation process by allowing users to create shortcuts for frequently used text segments. This tool can automate the insertion of standardized templates or common phrases into notes with just a few keystrokes, significantly reducing the time spent typing repetitive information.

Inpatient Progress Note Templates and Examples

Daily Care Note Template Copy Snippet Copied!

Patient ID and Room No.:
Date and Time:
Summary of Medical History:
Overnight Observations and Changes:
Medications Administered and Responses:
Plan for Today:

Daily Care Note Example

Patient ID and Room No.: 7896, Room 12A

Date and Time: April 22, 2024, 08:30 AM

Summary of Medical History: 65-year-old male with history of diabetes and hypertension.

Overnight Observations and Changes: Patient had mild chest pain around 2 AM, which resolved with sublingual nitroglycerin.

Medications Administered and Responses:
– Metformin 500 mg: Taken at dinner; blood glucose levels stable at 140 mg/dL.
– Nitroglycerin 0.4 mg sublingual: Administered for chest pain; pain resolved after 5 minutes, no further episodes.

Plan for Today:
– Continue monitoring blood glucose.
– Cardiology consult scheduled for further evaluation of chest pain.
– Increase hydration to improve renal function, currently at the lower limit of normal.

Consultation Note Template Copy Snippet Copied!

Patient ID and Date:
Referring Physician:
Reason for Consultation:
Findings and Recommendations:

Consultation Note Example:

Patient ID and Date: 7896, April 22, 2024

Referring Physician: Dr. Emily Tran

Reason for Consultation: Evaluation of uncontrolled hypertension in a patient with renal insufficiency.

Findings and Recommendations:
– Blood Pressure: 160/90, higher than target range.
– Renal Function: Slightly decreased; creatinine 1.8 mg/dL.
– Initiate a low dose of lisinopril, monitor for changes in renal function and potassium levels.
– Increase frequency of blood pressure checks to twice daily.
– Follow up in one week or sooner if symptoms of hypotension or worsening renal function occur.

Procedure Note Template Copy Snippet Copied!

Date and Time of Procedure:
Description of the Procedure:
Indication for Procedure:
Findings and Outcome:
Follow-up Care Instructions:

Procedure Note Example

Date and Time of Procedure: April 22, 2024, 10:00 AM

Description of the Procedure: Insertion of a central venous catheter in the right internal jugular vein.

Indication for Procedure: Need for central access for administration of long-term IV antibiotics.

Findings and Outcome:
– Procedure completed successfully without complications.
– Catheter placed in the right internal jugular vein, confirmed by X-ray.

Follow-up Care Instructions:
– Monitor site for signs of infection or thrombosis.
– Use aseptic technique for accessing the catheter.
– Regular dressing changes every 3 days or as needed.

Transfer Note Template Copy Snippet Copied!

Patient Information and Current Location:
Reason for Transfer:
Summary of Care Provided:
Updated Medical Plan:
Receiving Physician and Location:

Transfer Note Example:

Patient Information and Current Location: Patient ID 7896, ICU

Reason for Transfer: Improvement in respiratory status, requiring less intensive care.

Summary of Care Provided:
– Received mechanical ventilation for 3 days due to acute respiratory distress syndrome.
– Successfully weaned off the ventilator as of this morning.

Updated Medical Plan:
– Transfer to step-down unit for continued recovery and monitoring.
– Physical therapy to begin tomorrow to aid in mobility.
– Receiving Physician and Location: Dr. Laura Beck, Step-down Unit, Room 18B

Discharge Summary Template Copy Snippet Copied!

Patient ID and Admission/Discharge Dates:
Admission Diagnosis and Treatment Provided:
Condition at Discharge:
Follow-up Care and Medication Plan:
Contact Information for Follow-up:

Discharge Summary Example:

Patient ID and Admission/Discharge Dates: 7896, Admitted April 18, 2024, Discharged April 25, 2024

Admission Diagnosis and Treatment Provided: Acute respiratory distress syndrome; treated with mechanical ventilation and corticosteroids.

Condition at Discharge:
– Respiratory function restored to baseline.
– Patient alert, stable, and breathing comfortably on room air.

Follow-up Care and Medication Plan:
– Outpatient follow-up with pulmonology in one week.
– Continue corticosteroids for 2 more weeks, tapering dose.
– Contact Information for Follow-up: Pulmonology Clinic, Main Hospital, Tel: 555-123-4567

What is TextExpander

With TextExpander, you can store and quickly expand full email templates, Slack messages, and more anywhere you type. That means no more misspellings, no need to memorize complex instructions, or type the same things over and over again. See for yourself here:

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With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.

Patient ID and Room No. <br>Date and Time <br>Summary of Medical History <br>Overnight Observations and Changes <br>Medications Administered and Responses <br>Plan for Today
Patient ID and Date <br>Referring Physician <br>Reason for Consultation <br>Findings and Recommendations <br>
Date and Time of Procedure <br>Description of the Procedure <br>Indication for Procedure <br>Findings and Outcome <br>Follow-up Care Instructions
Patient Information and Current Location <br>Reason for Transfer <br>Summary of Care Provided <br>Updated Medical Plan <br>Receiving Physician and Location
Patient ID and Admission/Discharge Dates <br>Admission Diagnosis and Treatment Provided <br>Condition at Discharge <br>Follow-up Care and Medication Plan <br>Contact Information for Follow-up

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