Progress note examples

The structure of the daily note lives on progress note. This page is the content: for each common issue, what matters in today’s note. Trends, not single values; decisions, not workups.

Each example is one active issue, written as three lines

• Today: what to look at and write today: symptoms, the vitals and support that matter, the result that moved
• Response: what the treatment is doing: day of therapy, dose, effect, side effects
• Decision: what changes today, and who decided it

ACS

• Today: chest pain free or recurrent · ECG change from yesterday · troponin peak and falling · rhythm on telemetry
• Response: antiplatelets, anticoagulant day X · beta-blocker, statin, ACE inhibitor started or held and why · bleeding
• Decision: cardiology plan: angiography date or medical management · telemetry still needed · GRACE · MDCalc ↗︎ for risk if not yet done → chest pain

Heart failure

• Today: dyspnea and orthopnea · SpO₂ and oxygen flow from yesterday · weight and balance · JVP, edema, crackles
• Response: diuretic dose and the urine output or weight it produced · creatinine and K⁺ trend · foundational therapy started, held or titrated
• Decision: diuretic up, same or down · oxygen wean · echo result or date · SGLT2 inhibitor before discharge → dyspnea

Hypertensive emergency

• Today: BP trend over 24 h · headache, vision, chest pain, neurology · urine output and creatinine
• Response: IV agent and rate, or oral regimen · target reached or overshoot
• Decision: IV to oral switch · home regimen changes and the reason control failed · dialysis session if missed → hypertension

Asthma

• Today: speaking in sentences · wheeze and air entry · SpO₂ and oxygen flow · nebuliser frequency needed overnight
• Response: nebulisers spaced out or not · day of steroid course · magnesium given
• Decision: step down nebulisers · stop ipratropium after the first day · inhaler technique and the discharge inhaler plan → asthma

COPD

• Today: SpO₂ on the target 88–92% · gas trend if hypercapnic · NIV hours and whether it is coming off · sputum
• Response: nebulisers, steroid day X of 5, antibiotic day X and why
• Decision: NIV wean or stop · oxygen prescription · smoking and inhaler plan → COPD

Pneumonia

• Today: fever curve · SpO₂ and oxygen flow · RR · cough and sputum · confusion in the elderly
• Response: antibiotic day X of Y, dose adjusted to CrCl · cultures back · CRP or WBC trend
• Decision: IV to oral once improving and drinking · stop date · repeat CXR only at 6 weeks or if not improving · effusion drained or watched · CURB-65 · MDCalc ↗︎ on admission only → pneumonia

Stroke

• Today: deficit from yesterday, NIHSS · MDCalc ↗︎ if changing · swallow screen · BP and glucose · fever
• Response: antiplatelet or anticoagulant started and when · BP target · VTE prophylaxis · feeding route
• Decision: mechanism workup pending: echo, Holter, carotid imaging · rehabilitation goals · secondary prevention started → neurological deficit

Vertigo

• Today: still spinning or settled · able to walk · any new focal sign or headache
• Response: vestibular suppressant used, for how many days · tolerating oral
• Decision: stop suppressants early, mobilise · imaging only if a central sign appeared → neurological deficit

Delirium

• Today: 4AT · MDCalc ↗︎ or attention today vs yesterday · sleep · lines, catheter, bowels, pain · what triggered it
• Response: cause treated · sedatives and anticholinergics stopped · antipsychotic given, dose, QTc
• Decision: catheter out · drugs stopped · family at the bedside · when the cause is treated, the delirium is the thing to follow → delirium

Syncope

• Today: any recurrence · orthostatic BP today · telemetry events overnight
• Response: offending drugs held · fluids given
• Decision: echo or Holter result or date · telemetry can stop when · driving and safety advice before discharge → syncope

GI bleed

• Today: further melena or hematemesis · hemoglobin trend against transfusions · BP and HR · urea falling
• Response: PPI route · units given · antithrombotics held or restarted · endoscopy findings and treatment
• Decision: restart anticoagulant or antiplatelet when, with whom · PPI infusion to oral · diet · Glasgow-Blatchford · MDCalc ↗︎ on admission only → GI bleed

Pancreatitis

• Today: pain and analgesia need · tolerating oral intake · urine output and balance · SIRS features
• Response: fluids rate and whether it was reduced · analgesia · lipids or alcohol cause addressed
• Decision: feed today · stop IV fluids once drinking · imaging only if not improving at 48–72 h · gallstones: cholecystectomy plan → pancreatitis

Decompensated cirrhosis

• Today: encephalopathy grade and stools per day · ascites and weight · bleeding · fever · urine output and creatinine
• Response: lactulose titrated to 2–3 stools · diuretic dose and the sodium and creatinine it costs · antibiotic day X · paracentesis volume and albumin given
• Decision: diuretics up, hold or stop · SBP treatment or prophylaxis · Child-Pugh · MDCalc ↗︎ or MELD · MDCalc ↗︎ once for severity · hepatology plan → liver function

AKI

• Today: creatinine and K⁺ against yesterday and the baseline · urine output per hour · volume status
• Response: fluids or diuretics and what they did · nephrotoxins stopped · doses re-adjusted to CrCl (Cockcroft-Gault · MDCalc ↗︎)
• Decision: fluids continue or stop · ultrasound result · nephrology or urology input · dialysis triggers written → acute kidney injury

Nephrotic syndrome

• Today: edema and weight · BP · urine output · leg pain or dyspnea (thrombosis)
• Response: diuretic response · ACE inhibitor started · anticoagulation if given
• Decision: biopsy date · workup results back · nephrology plan → acute kidney injury

DKA

• Today: gas: pH, bicarbonate, anion gap · ketones · glucose and K⁺ trend · eating yet
• Response: fluid rate stepped down · insulin infusion rate · K⁺ replaced · precipitant treated
• Decision: resolution criteria met: stop the infusion 1–2 h after the first subcutaneous dose · basal insulin given · diabetes team and education → hyperglycemia

Hypoglycemia

• Today: episodes in 24 h with times and values · intake · symptoms recognised or not
• Response: what was given and how long it held · insulin or sulfonylurea doses reduced
• Decision: regimen change written · sulfonylurea stopped in renal impairment · cause found (missed meals, renal function, sepsis) → hypoglycemia

Anemia

• Today: hemoglobin against yesterday and the baseline · bleeding · symptoms · units given and the increment
• Response: iron, B12 or folate started · transfusion threshold used
• Decision: source workup: endoscopy date, hemolysis screen, film · transfuse only below the threshold → hemoglobin drop

Infection and sepsis

• Today: fever curve · lactate cleared · WBC and CRP trend · source signs: chest, urine, lines, skin, abdomen
• Response: antibiotic day X of Y, dose adjusted to CrCl · cultures back with sensitivities · source controlled: drain, line out, catheter out
• Decision: narrow or stop · IV to oral · total duration written · lines reviewed → fever, empiric antibiotics

VTE

• Today: leg or chest symptoms · SpO₂ and heart rate · bleeding on anticoagulation
• Response: anticoagulant, dose, day X · platelets and renal function for the dose
• Decision: provoked or unprovoked and the duration it implies · oral agent for discharge · cancer workup only if indicated → VTE

Stable chronic problems

• One line each, not rewritten daily: T2DM, stable on home regimen · CKD stage 3, creatinine at baseline
• A chronic problem moves up to the active issues the day it needs a decision, and back when stable
• The daily structure, medication review and close-the-loop items are on progress note