Documentation · Long-stay
Long-stay progress note
A full body-system approach for patients with prolonged admissions — early notes can be detailed, later notes can summarize active issues.
Basic header
- Date & time
- Patient name, age, gender, nationality
- Hospital number / MRN
- Ward & bed number
Summary & reason for prolonged stay
“[Patient] is a [age]-year-old [gender] of [nationality], admitted as a case of [diagnosis] on [admission / discharge date if readmitted].”
Briefly summarize why the patient remains admitted — e.g., ongoing infection, delayed discharge, rehab needs, medical optimization, etc.
General & vitals
- Vitals, GCS, fluid status
- Baseline vs current
- Devices: oxygen, IV lines, MV, catheters, drains
Neurology
- GCS and neuro exam
- Cognitive status ± sedation
- History: dementia, epilepsy, stroke, demyelinating diseases
- Imaging: CT / MRI, EEG, NCS / EMG
- Specialist input
- Meds: AEDs, antipsychotics, sedatives
Cardiology
- History: IHD, arrhythmia, HTN, heart failure
- ECG trends
- Echo findings (EF, valves)
- Troponin, BNP
- Meds: statins, beta blockers, antiplatelets, anticoagulants
Respiratory
- Oxygen support: nasal cannula, mask, BiPAP, CPAP, MV
- Tracheostomy: size, last change, plan
- Imaging: CXR, CT chest, HRCT
- VBG trends
- History: COPD, ILD, lung cancer
- Meds: steroids, nebs, prophylactic antibiotics
GI & nutrition
- Enteral vs parenteral feeding
- PEG / NGT details
- Stool chart
- History: liver disease, GI malignancy
- Imaging: ultrasound, CT, scopes
- Labs: LFTs, amylase, lipase
- Dietitian notes
Renal & urinary
- Foley details + last change
- Input / output + electrolyte status
- History: CKD, AKI, stones
- RFT, bone panel
- Imaging: KUB, ultrasound
Hematology
- CBC, coags
- Trends in Hb, platelets, WBC
- History: bleeding, transfusions, iron use
- Anticoagulants / antiplatelets
- If seen by hematology team
Infectious diseases
- Fever or new sepsis signs
- Cannula / line sites, wounds, ulcers
- CRP, PCT, CBC
- Cultures: blood, urine, sputum, wound
- Past antibiotics & resistance
- Meds: antibiotics, antivirals, antifungals
Endocrine
- DM status, insulin regimen, HbA1c
- Thyroid profile
- Vitamin D, calcium, DEXA (if relevant)
- Other endocrine history (e.g., adrenal, pituitary)
- Meds: insulin, thyroxine, etc.
Rheumatology & immunology
- CTD, arthritis, myopathies
- Allergies, immunosuppression
- Immunosuppressants, biologics, steroids
Limbs & vascular
- DVT signs
- Passive / active movement
- Vascular input if any
- Peripheral pulses
Additional reminders
- Document all active issues clearly
- Include all specialty consults & plans
- Don’t forget other domains: surgical, gyne, psychiatry, etc.
- Weekly labs: CBC, RFT, LFT, coags, CRP — repeat when needed
Devices & lines maintenance
| Device | Suggested change |
|---|---|
| Foley catheter | Every 2–3 months or earlier if infected |
| NGT | Every 4–6 weeks |
| Central line | Every 7 days or if signs of infection |
| Tracheostomy | Every 4–8 weeks |
| ETT | Review after 1–2 weeks → wean or trach |
- Remove unnecessary lines
- Document any changes in size, date, or complications
Final tips
- Always write the date, time, and your signature
- Mention the senior responsible for the plan
- Avoid copy-paste errors
- Endorse the patient before you hand over
- If unsure or the patient is unstable, ask for help
Your future self (or team) will thank you for writing a clear note.
Last reviewed · June 2026