Progress note

Documentation · Ward

Progress note

A structured, flexible format for your daily progress note — reflects your clinical reasoning, documents the patient’s current status, and keeps the next team in sync.

Date & patient identification

Always begin with the current date and time, followed by patient identification.

Template

[Patient name] is a [age]-year-old [nationality] [gender].

Known case of:

  • [e.g., T2DM since 2015]
  • [e.g., HTN on amlodipine]
  • [e.g., CKD stage 3]
  • [other relevant comorbidities]

Presented with: [brief HPI]
Admitted as a case of: [admission diagnosis]

Vitals & monitoring

  • Vitals: BP, HR, RR, temp, SpO₂, FBS/RBS
  • Fluids: IVF type + rate, I/O chart
  • Diet: e.g., NPO, diabetic, soft
  • Support: vasopressors, oxygen, or advanced support (if any)

Active issues

Use SOAP format (Subjective, Objective, Assessment, Plan) for each issue.

1. Hyperglycemia

S: no current symptoms; denies polyuria or polydipsia

O: FBS 10.3 mmol/L, on basal-bolus insulin

A: T2DM — glucose slightly elevated but stable

P: adjust rapid insulin dose before lunch; monitor pre-meal glucose

2. Pneumonia

S: mild cough, no SOB or chest pain

O: SpO₂ 96% on room air, RR 18, WBC 12; CXR → resolving infiltrates

A: improving bacterial pneumonia

P: continue IV ceftriaxone; reassess for oral switch in 48h

Pneumonia and other acute infections are covered in depth in MOC+ Volume 1: Acute Infections.

Chronic conditions (if stable)

If unchanged, document briefly:

Known T2DM since 2015, followed at [clinic]. On insulin. Last HbA1c 7.6%. No known complications.

No need to repeat daily — update only when relevant or if it becomes active.

Medications

List current inpatient meds, including any recent changes.

Seen in rounds

Patient seen during morning rounds with Dr. [senior’s name].

Plan with Dr. [name]

  • [e.g., continue antibiotics for 3 more days]
  • [e.g., repeat CBC/CRP tomorrow]
  • [e.g., refer to physiotherapy for mobilization]

Additional notes

  • Admission notes should be more comprehensive
  • Always include date, time, and signature
  • Always mention the senior in charge of the plan
  • Avoid careless copy-pasting — edit and personalize
  • Adapt based on the patient’s condition — this is a guide, not a checklist
  • If unsure or patient is unstable, ask early

Last reviewed · May 2026

MOC