progress notes

progress notes

Etymology: L, progredi + nota, mark
(in the patient record) notes made by a nurse, physician, social worker, physical therapist, and other health care professionals that describe the patient's condition and the treatment given or planned. Progress notes may follow the problem-oriented medical record format. The physician's progress notes usually focus on the medical or therapeutic aspects of the patient's condition and care. The nurse's progress notes, although recording the medical conditions of the patient, usually focus on the objectives stated in the nursing care plan. These objectives may include responses to prescribed treatments, the ability to perform activities of daily living, and acceptance or understanding of a particular condition or treatment. Progress notes in an in-hospital setting are recorded daily; those in a clinic or office setting are usually preceded by an episodic or interval history and are recorded as accounts of each visit.

pro·gress notes

(progres nōts)
Records kept by health care workers to indicate the course of the patient during care.

progress notes

An ongoing record of a patient's illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note. In patients who are not critically ill, a note concerning progress may be made daily or less frequently; for patients in critical care, notes may be made hourly. It is important that each note be clearly written, the date and time recorded, and the note signed.

progress notes

narrative records kept on changes in the animal's condition and treatment administered. In the problem-oriented medical record, it is written in the soap format.
References in periodicals archive ?
4 Prepares, authenticates and dates progress notes in legible detail at the time of visit.
It also looks for signs of progress and provides positive reinforcement with Progress Notes, which inform patients about the progress they are making in managing their diabetes and how often their blood glucose results are in range.
Fairways has recently become the first care home in the area to transfer all such care planning and progress notes 'to the cloud.
Multiple appropriate people can be in the record at the same time to review treatment plans and progress notes.
Given that many are already impatient with documenting within the physician documentation systems embedded in EHRs, those doctors, who often have received only minimal training in electronic documentation, create messy progress notes, using the copy-and-paste and copy-and-forward capabilities within EHR systems that readily enable "note bloat," with the equivalent of many pages of paper notes ballooning across computer screens nationwide.
FAMILIES PARTICIPATING in care through family care plans and progress notes, and residents and primary school children getting to know each other are two innovations registered nurse manager Jon Amesbury has introduced this year at Aria Gardens in Albany.
She encourages open communication and frequent status updates by providing daily progress notes on the general progress of the day, intermittent emails/texts of significant events accompanied by pictures, weekly raw data of the status of the student's IEP goals, email each Sunday evening to all parents with the schedule for the week, and data in graph format for interim and report cards.
teach beginning speech-language pathology students about the types of written and verbal communication they will encounter in university clinics, medical settings, and public schools: diagnostic reports, daily treatment plans, treatment reports, progress notes, professional correspondence, and electronic and verbal communication.
Physicians can login to Empower Inpatient + Ambulatory at MSMC via their iPhone/iPad to view Diagnostic Results, view Radiology Studies, write Orders, and even write Progress Notes.
Therefore, we optimized our use of the sections for free text comment, frequently prescribed orders and progress notes.
The RN has to somehow fit two very long and tedious medication rounds in each morning and afternoon shifts as well as look after the very sick (often palliative) residents, deal with their families, have staff meetings, replace staff when they call in sick, do dressing rounds, attend to doctors when they come in, write in the care plans, write in the progress notes, and if they manage a small miracle the RN may squeeze in a very shortened meal break.
The adolescent psychotherapy progress notes planner, 3d ed.

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