Progress note
Formal Definition
A daily note documenting the patient's status, overnight events, exam, labs, and updated plan. Usually SOAP format.
How It's Used on the Ward
"Write your progress notes" - daily documentation responsibility.
Example
"S: "Patient reports improved breathing. Slept well. No chest pain." O: "T 37.1, HR 78, BP 128/72, SpO2 97% on RA. Lungs: reduced bibasilar crackles." A/P: "CHF exacerbation improving. Continue diuresis, recheck BMP PM.""
Clinical Context
SOAP: Subjective, Objective, Assessment, Plan. Write your notes the same way every time so you don't miss anything.
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