progress notes

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.
References in periodicals archive ?
Our hypothesis was that by adopting a multimodal strategy, we would demonstrate an improvement to progress notes within the surgical department.
Did you sign all of your orders and progress notes for this patient?
She describes the basics of documentation, including the reasons for it, basic rules, different formats, how coding and documentation relate to reimbursement, and why documentation should focus on function; different types of services speech-language pathologists provide and how to document each, including evaluation, treatment plans, progress notes, and discharge summaries; documentation and reimbursement in different settings (acute care, inpatient rehabilitation facilities, skilled nursing facilities, home health, outpatient settings, and pediatric settings); and other types of writing, namely written communication and presentations.
Another 58% of claims involved user factors, such as copying and pasting progress notes. (Numbers do not add up to 100% because some claims had more than one cause.)
Several members confessed having a difficult time knowing how to appropriately write progress notes. Many felt doctors scrutinize their comments, while some expressed concern for over/under documenting relevant information in notes.
Pedrozo said the respondents failed to submit after five working days their affidavits and documents such as the cardiopulmonary clearance, documents stating the surgical operative technique, complete hospital chart and progress notes of the patient.
Progress Notes, Hand Ps, Images, Imaging Interpretations) for their patient population directly from their mobile device.
This information may include data from EHRs, radiology and pathology reports, lab results, doctors' progress notes, medical journals, clinical care guidelines, and published outcomes studies.
To assess the effect, we conducted a retrospective review of ambulatory progress notes written before and after 8 practice sites transitioned to the use of medical assistants as scribes.
The qualitative information was gathered from progress note documentation completed by the mentor (initial, bi-weekly, and final progress notes on each participant for each semester).
Fairways has recently become the first care home in the area to transfer all such care planning and progress notes 'to the cloud.'.

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