Patient Progress Notes
Health care services have to undergo several documentations for a smooth proceeding. One of such documents is the patient progress report which the physician or nurse drafted to exhibit the clinical status or health improvement accomplishments. These reports could be written for a hospitalized patient or for outpatient follow-ups. There are defined formats to write these patient progress notes. you can write the note in a SOAP format in which the progress is listed according to the Subjective, Objective, Assessment and Plan scheme or you can apply the DART format which progress as Description, Assessment, Response, and Treatment.
A progress note contains the reassessment details of patient’s clinical status and notes should be written in a way that it could clearly reflect the health status of your patient. Punctuation errors, abbreviations, and misspellings are called as noises in the progress notes. The more noises in your report the less authentic it is.
A readable, well-comprehended and concise format builds an effective progress notes. It should not be rigid to make any space for the modifications as series of irrelevant events may sometimes are responsible for a marked change in patient’s progress, which should be addressed in the progress report for clinical analysis. The reporter name and contact should also be stated in the report to reach the person in an emergency. Whatever format you are adopting; write every detail of patient’s progress with no error to provide a comprehensive health record in a compiled set-up.
MS Word Format
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