Progress note

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]

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

• Vitals: BP, HR, RR, temp, SpO₂, FBS/RBS
• Fluids: IV fluid type and rate, input/output chart
• Diet: e.g. NPO, diabetic, soft
• Lines and devices: peripheral cannula resite every 72–96 h · urinary catheter and central line reviewed daily for ongoing need · drains reviewed daily · all sites checked for infection
• Support: vasopressors, oxygen, or advanced support (if any)

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

For more worked examples by body system, see progress note + examples.

For each condition note

• Diagnosis and since when · who follows it up · compliant or not · medication side effects · complications of the disease

e.g. Known T2DM since 2015, followed at [clinic], compliant on insulin with no side effects, last HbA1c 7.6%, no known complications.

No need to repeat daily; update only when it changes or becomes active.

List current inpatient medications, including any recent changes.

Review daily

• Switch IV to oral once the patient can tolerate it
• Stress-ulcer prophylaxis (PPI): continue only if indicated
• DVT prophylaxis

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

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

• Always mention the senior in charge of the plan
• Avoid copy-pasting; personalize each note