progress note

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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When the provider writes a clinical progress note, the system automatically creates an item in the billing system.
Perhaps that information is helpful for the billing department, but it doesn't belong in a progress note.
The daily progress note is the building block for quality care and monitoring.
For example, a CNA's vague estimate of the time an event occurred may be refined by an activity roster and a progress note documenting a specific program in which the resident was participating.
With two summary tables, patients information sheets, sample scripts about how to address the key issues in PEP and even a sample progress note, they offer a user-friendly, slightly different perspective on some key issues.
Program highlights include: RehabWorks DataLink, our new data feed, which eliminates the need for facilities to manually enter data; RehabPlus Consulting, select nursing and financially-based therapy consultation services provided by Polaris Group; Restorative Rehabilitation Nursing Program Manual with consultation; Facility-based educational programs with CEU's; Census Development Program Manual with consultation; Progress Note Billing System; Recapture The Strength Senior Wellness Programs; and Compliance and Quality Assurance Programs.
Any progress note entry from a category button follows the basic procedure outlined below for entering the student/patient contact hours:
As noted in our article, the photocopy of the medical record was of the progress note from the patient's previous visit only and was handed to patients at the time of their subsequent office visit, so there were no mailing costs.
The CD-ROM contains printable worksheets, therapist tools like progress note templates, quizzes, sample scenarios, and handouts.
Although our interest was in extracting the progress note for the specific record that included the specialty code, no method exists for precisely matching records located in VHA administrative data to a specific progress note.

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