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progress note

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progress note
A brief summary of a hospitalized Pt's current clinical status, written sequentially in the chart, reflecting information provided by physical exam, lab tests, and imaging modalities. See Hospital chart.


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It includes some progress notes and plans for further sessions.
There are also recommendations on administrative and business issues, plus 13 pages of sample forms and templates, including patient information forms, progress notes, and a letter of medical necessity.
Rather than staff keyboarding in a client's information for, say, a progress note, the staff member pulls out his/her handy pen and writes the information down.
 
 
 
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