Progress note
Progress Note
A Progress Note (pronunciation: /ˈprəʊɡrɛs noʊt/) is a document that healthcare professionals use to record details about a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care.
Etymology
The term "Progress Note" is derived from the English words "progress" and "note". "Progress" (from Latin progressus, "advance, progression") refers to the forward or onward movement towards a destination. "Note" (from Latin nota, "mark, sign, note") refers to a brief record of facts, topics, or thoughts, written down as an aid to memory.
Structure
Typically, a Progress Note includes the following sections:
- Subjective: This section includes the patient's symptoms and feelings, as reported by the patient.
- Objective: This section includes factual, measurable data, such as observable signs and diagnostic test results.
- Assessment: This section includes the healthcare professional's evaluation of the patient's current condition.
- Plan: This section includes the healthcare professional's plan for tests and treatments that will be used to manage the patient's condition.
Related Terms
- Medical Record: A comprehensive document that includes a patient's medical history, including diagnoses, treatment plans, progress notes, and more.
- SOAP Note: A method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note.
- Patient History: Information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information.
See Also
External links
- Medical encyclopedia article on Progress note
- Wikipedia's article - Progress note
This WikiMD dictionary article is a stub. You can help make it a full article.
Languages: - East Asian
中文,
日本,
한국어,
South Asian
हिन्दी,
Urdu,
বাংলা,
తెలుగు,
தமிழ்,
ಕನ್ನಡ,
Southeast Asian
Indonesian,
Vietnamese,
Thai,
မြန်မာဘာသာ,
European
español,
Deutsch,
français,
русский,
português do Brasil,
Italian,
polski