There is no way to know who may read the progress notes you write on your patients. While your readers will most often include members of your own team (intern, resident, attending) and the other health workers caring for that patient (nurses, physios, social workers, etc.), your note potentially could be read by anyone who takes an interest in that patient. Therefore, it’s a good idea to know how to write a good note.
Writing a good progress note generally requires four things:
Check Epic to read about the patient’s medical and surgical history, medications, imaging reports, lab results, vital signs
Read progress notes and orders written since you last saw your patient.
Finally, SEE YOUR PATIENT to ask how they have been since you last saw them and do a physical exam.
Components of a good note
First, write the date and time*.
On the top line, write the name of your service* (examples: “IM-4”, “Vasc Surg”, “Gyn-Onc”, “Gen Peds”) as well as “MS-3*” or “MS-4” (MS = med student, followed by your year).
Start with your subjective review^ of the patient (usually 3-5 lines), including any events or developments since you or your service last saw the patient.
Next comes the physical exam^:
Start with vitals (T, BP, HR, RR, perhaps SpO2).
Then list the results of your PE. (Each specialty has its own way of reviewing the PE. Learn your service’s way and follow it.)
Then list lab results* (usually only those that have come back since the last time your service wrote a note on the patient).
If your patient’s ins-and-outs^ are being monitored, include this as well.
Next, list any investigations that have been done since your last note on the patient, and what the results were.
Give your assessment and plan*. This is where you tie it all together:
Start with a one- or two-line summary of your patient’s age, sex, and chief (presenting) complaint;
List your patient’s problems and what is being done to address them, both non-pharmacologically and pharmacologically.
Finally, sign your name* (print legibly) and again write, “MS III” or “MS IV”.
* These are things that should included in your note every time, regardless of which rotation or service you are on.
^ These are things that will vary significantly in your note (e.g. in focus, in length) depending on what rotation and service you are on.
Things not to forget
The date and time and name of your service. Gotta have this.
The physical exam should almost always begin with a review of vital signs.
The assessment and plan should begin with a concise summary of the patient’s identity and chief complaint (CC).
Sign your name.
A cardinal sin
We know, we know – it’s reeeally early in the morning, you’re pressed for time, rounds are about to begin, and your patient keeps on talking. Nevertheless, the worst mistake you can make is to FAIL TO SEE YOUR PATIENT. You may get away with it … but if you don’t, it will be a black mark on your attending’s and resident’s view of you.
If you’re not sure what info to include in your note, look at a note written earlier by an intern or resident. Their notes should clue you in to what aspects of care are pertinent to your patient, and how that information has been recorded before.