Progress Notes is essentially the final part of a patient’s medical history, which contains details to record a patient’s medical condition or accomplishments over the duration of a hospitalization or throughout the course of outpatient therapy. While the term “Progress Note” may conjure up images of doctors scribbling in a notebook or office pad, in reality a progress note is much different than one. Unlike a journal, progress notes are more like personal diaries or even a snapshot in time. As such, they must be fluid and precise, capturing all the relevant information that can change a patient’s care within a few hours of their caretaking.
Doctors who order progress notes for patients tend to order them so that other health professionals and hospitals in the patient’s case will be able to read them as well. The more detailed the note, the more helpful it will be as a reference material for a doctor or other medical professional. This means that doctors or other health care providers will want to have the option of referring to the notes when making a diagnosis or treatment decision. Similarly, hospital staff will use the notes to confirm that a patient has been discharged, and when a discharge date is not set, they can look to the progress note to confirm that the patient will be able to stay at the hospital. This latter point is particularly important because sometimes a patient may be hospitalized for non-related issues that cannot be related to the heart ailment or other serious condition that prompted the original hospital admission.
All progress notes follow the same general format, though the actual content can vary from hospital to hospital and doctor to doctor. They will most often contain basic information like the patient’s name, age, and general health. However, progress notes can also include more detailed information regarding a patient’s medical condition or other factors which were known about before the hospital admission.
Generally, progress notes are ordered by category. For example, the first category, emergency carers, describes professionals who come into contact with the patient in an emergency such as nurses, paramedics, and members of the emergency medical services team (police, ambulance, and hospital staff). The next category, intermediate carers, includes people like dental assistants, dietitians, and personal care assistants who work with intermediate healthcarers on a regular basis. The final category, specialized carers, falls under the list of specialised healthcare staff who work with a physician only. These professionals include physicians, surgeons, consultants, and other medical and nursing personnel.
In addition to the categories listed above, a progress note will most likely contain a short description about what the patient did during the previous week. This description, called a progress statement, can go into more detail about the activities and situations that the patient encountered, as well as their interaction with the medical and/or health carer(s). Progress notes are very useful not only for healthcare professionals but also for patients and carers, as they can give detailed information about what is going on with one’s body as well as an overview of one’s progress over time. This can help people plan their healthcare so that they will be able to achieve the best outcome for their individual condition. It can be used to track one’s own health as well as to give feedback to doctors, other health professionals, and family members as needed.
Progress notes may also be used for other purposes, although they are most commonly used in hospitals. A health practitioner can use these notes to compile a long-term health record for a patient, so that he or she will have a better understanding of the patient’s healthcare history and current state of health. This information can then be shared between healthcare providers and families, and anyone involved in a patient’s care who needs it can access the notes to get the information that they need quickly. Similarly, progress notes may be used by schools to help them build up a better educational healthcare system by helping students and teachers to identify problem areas and review various forms of documentation related to that problem.