What is required in a daily hospital progress note?

Daily hospital progress notes must include: date and time, overnight events, subjective patient status, vital signs with trends, focused physical exam, review of new lab/imaging results, assessment of each active problem with status update, updated plan for each problem, and discharge planning status. This supports medical necessity for continued hospitalization.

What CPT codes are used for daily hospital progress notes?

Subsequent hospital care codes are 99231 (straightforward/low MDM), 99232 (moderate MDM), and 99233 (high MDM). Most routine hospital progress notes qualify for 99232. Use 99233 for critically ill patients or complex decision-making. Only one subsequent care code per day per provider is billable.

How do I document to support 99233 subsequent hospital care?

99233 requires high MDM complexity: document acute illness with severe exacerbation or new problem with severe systemic illness, extensive data review (independent interpretation of tests, discussion with external physicians), and high-risk treatment decisions (drug therapy requiring intensive monitoring, decision regarding hospitalization). Include clear clinical reasoning.

What should be included in the overnight events section?

Document significant overnight occurrences: vital sign changes, new symptoms, nursing concerns, PRN medication use, procedures performed, consultant recommendations, family calls, code status discussions, and any clinical deterioration or improvement. This demonstrates continuous care and supports medical necessity.

How do I document discharge readiness in daily notes?

Document discharge criteria: medical stability (vital signs, lab trends), functional status (mobility, ADLs), pending items (tests, consultations, teaching), discharge barriers (social, equipment, placement), anticipated discharge date, and discharge disposition (home, SNF, rehab). Update daily to track progress toward discharge.

Daily Progress Note Template - Hospital Rounding Note

Daily Progress Note

Date: [Date] Hospital Day: [X] Admission Date: [Date] Attending: [Name]

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Overnight Events

[ ] No significant overnight events

Vital sign changes: [Details]
Nursing concerns: [Details]
PRN medications: [Medications given, reason, response]
Code/RRT: [If applicable]
Consultant input: [New recommendations]
Family contact: [Updates, concerns]
Other: [Significant events]

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Subjective

Patient Status:

Current symptoms: [What patient reports]
Pain: [X]/10 — Location: [If applicable] — Current regimen: [Adequate/Inadequate]
Sleep: [Good/Fair/Poor]
Appetite: [Eating X% of meals]
Bowel function: [Last BM date]
Activity: [Ambulating/OOB/Bedrest]
Mood: [Appropriate/Concerns]

Overnight concerns reported: [None / Details]

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Objective

Vital Signs (with 24-hour trend)

Time	BP	HR	RR	Temp	SpO2
Current	[X/X]	[X]	[X]	[X]°F	[X]% on [RA/O2]
Tmax/low	[X/X]	[X]	-	[X]°F	[X]%

I/O (24h): In: [X] mL / Out: [X] mL — Net: [+/-X] mL Weight: [X] kg — Change from admission: [+/- X] kg

Physical Examination

General: [Alert/Oriented x4] / [Appearance, distress level] Cardiovascular: [Rate, rhythm, murmurs, JVP, edema] Respiratory: [Breath sounds, work of breathing, O2 requirement] Abdomen: [Soft, BS, tenderness, distension] Extremities: [Edema grade, pulses, skin] Neuro: [Mental status, focal findings] Lines/Drains: [PIV, central line, Foley, drains — status] Skin: [Pressure injuries, wounds, rashes]

Laboratory Results

Test	Today	Yesterday	Trend
WBC	[X]	[X]	[↑↓→]
Hgb	[X]	[X]	[↑↓→]
Plt	[X]	[X]	[↑↓→]
Na	[X]	[X]	[↑↓→]
K	[X]	[X]	[↑↓→]
Cr	[X]	[X]	[↑↓→]
BUN	[X]	[X]	[↑↓→]
Glu	[X]	[X]	[↑↓→]

Other significant labs: [Results]

Imaging/Studies

[New imaging and interpretation]
[Pending studies]

Consultations

[Specialty]: [Recommendations, status]

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Assessment by Problem

1) [Primary Diagnosis] — [Improved / Stable / Worsened]

Supporting evidence: [Key clinical data points]
Hospital course: [Brief trajectory]

2) [Problem 2] — [Status]

[Assessment]

3) [Problem 3] — [Status]

[Assessment]

Secondary/Chronic Conditions:

[Condition]: Stable, continue current management

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Plan by Problem

1) [Primary Diagnosis]

[ ] Continue: [Current effective treatments]
[ ] Adjust: [Medication/treatment changes]
[ ] Order: [New labs, imaging, consults]
[ ] Monitor: [Parameters, frequency]
[ ] Goals: [Target values, clinical milestones]

2) [Problem 2]

[ ] [Plan items]

3) [Problem 3]

[ ] [Plan items]

Routine/General Care

Diet: [Type]
Activity: [Level, PT/OT involvement]
DVT prophylaxis: [Method]
GI prophylaxis: [If indicated]
Glycemic control: [Protocol if applicable]
Code status: [Status] — Readdressed: [Yes/No change needed]

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Discharge Planning

Anticipated Discharge: [Date] / Not yet determined Disposition: Home / Home with services / Rehab / SNF / LTACH Criteria for Discharge:

[ ] Medically stable (VS, labs normalizing)
[ ] Tolerating PO intake/medications
[ ] Adequate pain control
[ ] Functional mobility
[ ] Discharge medications reconciled
[ ] Follow-up arranged
[ ] Patient/family teaching complete

Barriers to Discharge:

[ ] None identified
[ ] Medical: [Specify]
[ ] Social: [Specify]
[ ] Placement: [Specify]
[ ] Equipment/DME: [Specify]

Case Management: [Involved/Needs to be involved]

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Today's Priorities

1. [Most critical action item]
2. [Second priority]
3. [Third priority]
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Attestation

Patient examined, chart reviewed, and plan discussed with [resident/team]. I agree with the assessment and plan as documented above with the following additions/modifications: [None / Specify]

Daily Progress Note Template — Hospital Rounding Documentation

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