Progress Note

This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter.

Taber's medical dictionary defines a Progress Note as "An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note."

Mosby's medical dictionary defines a Progress Note as "Notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned."

A Progress Note is not a re-evaluation note. A Progress Note is not intended to be a Progress Report for Medicare. Medicare B Section 1833(e) defines the requirements of a Medicare Progress Report.

Systems shall include the full narrative Progress Note in an appropriate section. Acceptable sections include the Assessment, Plan of Treatment, Assessment and Plan, or Note sections. In all cases, the narrative Progress Note shall be wrapped within a Note Activity Act to ensure proper ingestion.

#### Document Sections Although document templates may contain any section, the following sections are specifically called out by this template:

Required Sections

• AssessmentandPlanSection or both AssessmentSection and PlanofTreatmentSection

Additional Sections

• AllergiesAndIntolerancesSection
• ChiefComplaintSection
• ActivitiesSection
• InstructionsSection
• MedicationsSection
• ObjectiveSection
• PhysicalExamSection
• ProblemSection
• ResultsSection
• ReviewofSystemsSection
• SubjectiveSection
• VitalSignsSection
• NutritionSection
• MentalStatusSection
• AdvanceDirectivesSection
• NotesSection