how to write a progress note
a good progress note should reflect your clinical reasoning, document the patient’s current status, and communicate your plan clearly to the next team. here’s a structured, flexible format you can use daily.
📆 date & time
always begin with the current date and time.
🧾 patient identification
[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.
example:
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
🧾 chronic conditions (if stable)
if unchanged, document briefly like this: 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