Progress Note Template — Daily Medical Documentation
The Progress Note Template is designed for physicians, nurse practitioners, and physician assistants documenting daily patient encounters in inpatient, outpatient, and long-term care settings. This versatile template captures interval changes, response to treatment, clinical status updates, and ongoing care plans. The format supports appropriate E/M billing (99212-99215 outpatient, 99231-99233 inpatient) while ensuring continuity of care across encounters. Key sections include overnight events and interval history, subjective patient status, focused objective findings with vital sign trends, assessment of each active problem with clinical reasoning, and updated plan with next steps. This template is adaptable for hospital progress notes, nursing facility rounds, outpatient follow-ups, and subspecialty monitoring visits. Ideal for hospitalists, primary care providers, specialists, and any clinician documenting ongoing patient care.
Template
Progress Note
Date: [Date] Visit Type: Progress Note / Follow-up / Daily Rounding Note Time: [Time of encounter]---
Interval History
Since Last Encounter
Days since last visit/admission: [X]
Significant events: [New symptoms, procedures, consultations]
Overnight events (if inpatient): [Code calls, vital sign changes, nursing concerns]
Current Status
Patient reports: [Current symptoms, concerns, changes]
Pain level: [X]/10 — Location: [If applicable]
Sleep: [Quality]
Appetite: [Good/Fair/Poor]
Activity level: [Bedrest/Limited/Ambulatory]
Functional status: [Any changes]
Response to Treatment
Medications: [Tolerating/Side effects/Effectiveness]
Therapy response: [If applicable]
Overall trajectory: Improving / Stable / Declining
---
Review of Systems (Focused)
Constitutional: [ ] Fever [ ] Chills [ ] Fatigue
[Relevant systems based on active problems]
All other systems negative or unchanged from prior.
---
Objective
Vital Signs
BP: [X/X] — Trend: [Stable/Improving/Worsening]
HR: [X] — Rhythm: [Regular/Irregular]
RR: [X]
Temp: [X]°F (Tmax: [X]°F)
SpO2: [X]% on [RA/O2 at X L]
Weight: [X] kg — Change: [+/- X kg]
I/O (if inpatient): [X]/[X] mL
Physical Examination (Focused)
General: [Appearance, alertness, distress] Cardiovascular: [Heart sounds, rhythm, edema, JVP] Respiratory: [Breath sounds, work of breathing, oxygen requirement] Abdomen: [Soft, bowel sounds, tenderness, distension] Extremities: [Edema, pulses, skin changes] Neurological: [Mental status, focal findings if relevant] Other: [System-specific findings relevant to active problems]Diagnostic Results
Laboratory (New/Significant):- [Test]: [Result] (Prior: [X])
- [Test]: [Result] (Prior: [X])
- [Study]: [Interpretation]
- [EKG, cultures, etc.]
---
Assessment
Problem List with Status
1) [Primary Problem] — [Improved / Stable / Worsened]Clinical reasoning: [Evidence supporting assessment]
- Contributing factors: [If applicable]
- Response to treatment: [Effective/Partial/Inadequate]
[Assessment]
3) [Problem 3] — [Status][Assessment]
Additional Active Problems
- [Other ongoing conditions]
---
Plan
Problem 1: [Primary Problem]
- Continue/Adjust/Discontinue: [Current treatments]
- New interventions: [Medications, procedures]
- Monitoring: [Labs, vitals, clinical parameters]
- Goals: [Target values, milestones]
Problem 2: [Problem Name]
- [Plan details]
Problem 3: [Problem Name]
- [Plan details]
General Care (If Inpatient)
- Diet: [NPO/Clear liquids/Regular/Other]
- Activity: [Bedrest/OOB to chair/Ambulatory]
- DVT prophylaxis: [Heparin/Lovenox/SCDs/Ambulation]
- Code status: [Full code/DNR-DNI/Other] — Discussed: [Yes/No change]
Consultations
- Pending: [Specialty, reason]
- Completed: [Specialty, recommendations]
Discharge Planning (If Inpatient)
- Barriers to discharge: [None/Medical stability/Social/Other]
- Anticipated discharge: [Date/Not yet determined]
- Disposition: [Home/Rehab/SNF/Other]
- Needs at discharge: [Home health/DME/Follow-up]
---
Plan for Next 24 Hours
Key priorities:
1. [Critical monitoring or intervention]
2. [Important decision point]
3. [Pending results to follow]
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Patient/Family Communication
Discussed with: Patient / Family / [Relationship]
Topics covered: [Current status, plan, prognosis]
Questions addressed: [Yes/None]
Patient/family understanding: Verbalizes understanding of plan
💡 Tip: Click anywhere to edit. Changes are temporary.
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