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 ?
Reasons for the usage of antipsychotic drugs must be documented on the physician's orders or progress note and in the patient care plan.
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.
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.
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.
Physicians dictated a summary progress note, using a unique feature within the Practice Partners EMR.
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.
Procedures entered into the progress note should be automatically sent to the billing system-creating the appropriate bill.
The system includes codes that allow information contained in the progress note to automatically update other sections of the chart.
Through an iterative process over several months with senior attending surgeons and residents, our working group identified and differentiated important and superfluous Information within the surgical progress note. The goal was to use group consensus throughout the process of creating a more-streamlined template and move away from notes that were data-rich but information-poor.
A progress note reflected that she was in no acute distress.<br />On Monday, the patient was taken to the operating room for diagnostic laparoscopy.
The progress note was cosigned several hours later by the attending physician.
The progress note is an important vehicle for describing care provided and transferring information among physicians caring for the same patient.

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