A member asked:

What information should be contained in a progress note?

2 doctors weighed in across 2 answers

The basics. What the patient said, what the doctor observed/found. What the doctor decides it means. What they plan to do about it. The write up can be brief or run pages.

Answered 4/24/2023

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Dr. Silviu Pasniciuc answered

Specializes in Internal Medicine

Pertinent subjective events, objective exam, an assessment and plan, including estimated discharge or what has to happen prior to discharge are the main elements in an inpatient progress note.

Answered 4/24/2023

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