Documentation · Ward
Progress note
Patient
Template
[Patient name] is a [age]-year-old [gender], known case of [chronic conditions, one line].
Admitted on [date], day [X] of admission, as a case of [admission diagnosis].
This line stays the same every day; only the day count changes.
Current status
- Vitals: BP · HR · RR · temperature · SpO₂ · glucose, with the trend (afebrile 24 h, SpO₂ 95% on 2 L from 4 L)
- Support: oxygen device and flow · vasopressor dose · NIV or other support, and whether it went up or down
- Fluids: IV fluid type and rate, or none · input and output, balance · weight if charted
- Diet: regular · diabetic · soft · NPO and why
- Lines and devices: cannula, catheter, central line, drains · days in · still needed or out today
- Mobility: bed · chair · walking, with or without help
Quick guide: lines and devices
- Peripheral cannula: resite every 72–96 h, or sooner if the site is red or painful
- Urinary catheter and central line: ask daily whether it is still needed; the answer is written in the note
- Drains: output and character daily, remove when the reason is gone
- Every site checked for infection; a new fever starts with the lines → fever
Issues
Each active issue gets four lines. The O line is the change since yesterday, not a repeat of the value.
1. Pneumonia
S: cough less, no dyspnea or chest pain
O: afebrile 24 h, SpO₂ 95% on 2 L from 4 L, RR 18, WBC 12 from 16; day 3 of ceftriaxone
A: improving
P: switch to oral antibiotic today if still afebrile this evening, total 5–7 days; wean oxygen to room air
2. Hyperglycemia
S: no polyuria or hypoglycemia symptoms
O: fasting 10.3 mmol/L from 12.1, pre-lunch 11.8; on basal insulin plus correction
A: improving, not at target
P: increase basal insulin by 10%, keep pre-meal and bedtime checks
Resolved issues drop off the list with one closing line. More worked examples by system → progress note examples.
Chronic
- Stable chronic problems: one line each, not rewritten daily
- e.g. T2DM, stable on home regimen · hypertension, controlled · CKD stage 3, creatinine at baseline
- A chronic problem moves up to Issues the day it needs a decision, and moves back when stable
Medications
- Medication review: continue · stop · restart · IV to oral · dose adjustment · reason
- Antibiotics: drug, day X of planned Y, stop or review date
- VTE prophylaxis: continuing, or why not
- Held home medications: which, why, and when they restart
- PRN use in the last 24 h: analgesia, antiemetic, sedation; a pattern is an issue
Quick guide: medication review prompts
- IV to oral once improving, tolerating oral intake and an active oral option exists; no arbitrary afebrile wait → empiric antibiotics
- Creatinine changed → re-dose antibiotics, LMWH, opioids, gabapentinoids, DOACs → Cockcroft-Gault · MDCalc ↗︎
- VTE prophylaxis: still indicated, platelets and bleeding risk unchanged, dose right for weight and CrCl
- PPI: still indicated, or started in ICU and never stopped
- Held medications: the reason gone? restart today, or write when
- Full admission-day changes → admission note
Plan
- By issue, one line each: what changes today
- Trends, not isolated values: creatinine 140 from 180 · Hb 9.1 from 9.8 · lactate cleared
- Investigations only if the result changes a decision; no routine daily bloods
- What we are waiting for, and the date it moves the plan
Close the loop
- Pending results: what · when · what to do if abnormal
- Consults: recommendations received, done or pending
- Reassess: when, after what
- Discharge barriers: what stands between the patient and home, and who owns it → discharge summary
- Senior discussion: seen on rounds with Dr X, decisions made
- Patient and family: updated on what, when relevant
- Handover: what needs following tonight → handover
Last clinically reviewed · June 2026 · Last updated · October 2026
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