What are Progress Notes?
Progress Notes are clinical records used to document the daily updates of a patient’s condition, treatment progress, and any interventions performed. They are typically used in long-term care settings, nursing, and hospital care to track a patient’s condition over time.
📝 What are Progress Notes?
Progress Notes are clinical records used to document the daily updates of a patient’s condition, treatment progress, and any interventions performed. They are typically used in long-term care settings, nursing, and hospital care to track a patient’s condition over time.
Progress Notes are a key component of ongoing patient care, helping clinicians to monitor changes, document interventions, and ensure that care is provided consistently. They are useful in both acute and chronic care environments, including general practice and specialist settings.
✏️ Structure
Progress Notes are typically shorter than Comprehensive Clinical Notes, but still capture the essential components needed for effective care:
| Section | Description |
|---|---|
| Date/Time | The date and time the progress note was written or updated. |
| Presenting Issue | A brief description of the patient's current condition or concern. |
| Current Symptoms | Ongoing symptoms or changes in the patient’s condition since the last visit. |
| Interventions/Actions | Actions or treatments provided, including medication adjustments, therapies, or patient education. |
| Progress | Evaluation of the patient’s progress since the last note. This may include improvement, worsening, or stabilization of symptoms. |
| Plan | The next steps for the patient, including follow-up care, further investigations, or medication changes. |
| Signature | The healthcare provider’s signature or initials, confirming the note was written. |
🏥 When are Progress Notes used?
Progress Notes are essential when a patient requires ongoing assessment, particularly for:
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Nursing care in hospitals or care homes
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Chronic disease management
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Post-surgical recovery
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Multidisciplinary care teams
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Mental health follow-ups
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Home care visits
They can also be used by GPs for regular check-ins on patients with ongoing treatment needs, ensuring continuity of care.
👥 Who uses Progress Notes?
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Nurses for daily care updates
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Doctors for ongoing patient evaluations and follow-ups
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Physiotherapists and other allied health professionals to track rehabilitation progress
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Mental health professionals for regular check-ins on psychiatric patients
🌍 Where are Progress Notes available?
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Australia and New Zealand
Progress Notes are used extensively across both regions in hospitals, general practices, and aged care facilities. They are commonly used within Medtech Evolution or other healthcare record systems.
🔄 Key Differences from Other Note Types
Unlike other more detailed note formats like SOAP or Comprehensive Clinical Notes, Progress Notes are typically more focused on daily updates and shorter summaries. They do not capture the full range of historical medical data, instead focusing on what is happening now and what needs to happen next.