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.
References in periodicals archive ?
Issues addressed are health maintenance protocols, outline of a progress note, dating of notes, legibility, problem lists, and medication lists.
The HIPAA-ready software package includes office scheduling, interoffice messaging, advanced patient search capabilities, lCD and CPT coding, and prescription writing as well as complete progress note documentation of medical encounters.
RehabWorks DataLink, in combination with RehabWorks' exclusive Progress Note Billing System(TM), enhances audit-defense readiness by helping to ensure that billing matches the medical record.
Thus, if a progress note is referenced as a "Location," that note must remain with the record for at least two years.
Features of Blue Iris include a single view of patient information in a SOAP progress note format, dynamic views of data that allow physicians to see ranges of data from hours or weeks with the click of a button, and the integration of images such as X-rays with the rest of the patient's data.
Reasons for the usage of antipsychotic drugs must be documented on the physician's orders or progress note and in the patient care plan.
For example, most doctors want to see their latest progress note, but some doctors may not care about seeing incoming correspondence or the last lab culture.
Lastly, the Comprehension Check module augments the progress note documenting the informed consent discussion with the specific details related to the patient's comprehension of all aspects of the proposed procedure.
When the progress note was loaded into the system, key elements within the progress notes, such as problems and allergies, could be parsed into the appropriate section of the chart.
Minutes of the meeting inform all staff members of residents involved in the programs, provide an update of individual residents, a progress note, and inform the Director of Nursing Services of committee activity.
The formatting involves placing markers (dot codes) within the transcription that allow the program to identify the patient and download the progress note into the appropriate chart when the EMR is implemented.

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