Interval history note
Formal Definition
A documentation entry that summarizes the clinical events and changes that occurred since the last assessment (often since admission or the last comprehensive note) — a focused update that highlights new symptoms, changes in existing symptoms, new findings on examination, new test results, treatment changes and responses, and the ongoing assessment/plan; required daily in inpatient settings as part of progress notes, also used for outpatient visits documenting what's happened since the last appointment.
How It's Used on the Ward
"Interval history" or "interval events" — the lead-in to most daily progress notes and many outpatient notes; "interval events" lists what's changed since yesterday or since the last assessment; serves as the cognitive anchor before subjective and objective updates.
Example
""DAILY PROGRESS NOTE — 02/14/2026: INTERVAL: Patient was admitted 3 days ago for COPD exacerbation. Overnight he had improved dyspnea, slept better after BiPAP was held. No new fevers, no chest pain, continuing to clear sputum. CXR this AM showed decreased infiltrate from admission. SUBJECTIVE: Patient reports feeling "much better," breathing easier, no complaints other than dry mouth. OBJECTIVE: T 37.1, HR 78, BP 124/78, RR 18, SpO2 92% RA. Lungs: scattered wheezes, no crackles. Heart RRR. Abdomen: soft, non-tender, bowel sound present.""
Clinical Context
Standard inpatient progress note format: INTERVAL (or interval events/subjective) — what's happened since last note; OBJECTIVE — current vital signs, physical exam, labs, imaging; ASSESSMENT — problem-based clinical reasoning with one-liners; PLAN — what to do for each problem. Outpatient interval history: what's happened since the last visit (new symptoms, completed tests, hospitalizations, medication changes); often led by patient in their own words. Documentation principles: focus on what's changed (not what's static — copy-forward if needed for stable items); highlight clinically meaningful changes; incorporate nursing, family, patient observations; reference new lab/imaging results explicitly. Legal importance: daily progress notes are medico-legal records of what the team was thinking and doing; auditor scrutiny often focuses on whether interval events match the corresponding assessment/plan. Common error: interval history says "unremarkable" or "no change" but significant clinical changes are buried elsewhere in the note — explicit documentation of meaningful changes improves clarity.