Date
of Last Review: 5/19/08
SME: Associate Director of Nursing
Progress notes are written in the chart to document the patient's status or
achievements in aspects of treatment and discharge. Reassessment data may be
recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.
Progress note entries in the patient record are maintained in chronological order by date in the chart as follows:
 | Physicians begin all lines of their progress noting at the left edge of the progress note form. |
| Nursing staff begin all lines of their progress noting at the first indented line from the left edge. |
| All other disciplines begin progress notes at the second indented line from the left edge. |
Date and Time: Each note must begin with the date and time.
Progress Notes address:
| Documenting the patient's current status in treatment |
| Significant change in patient's condition |
| Significant change in patient's diagnosis |
| The patient's problem(s) prioritized by the physician on the master treatment plan. |
Progress notes may also include, but are not limited to, the following:
|
|
| Results of Goal-Related Testing |
| Patient Response to Planned Intervention |
| Patient/Family Education |
| Unexpected Occurrence Related to Problems/Strengths |
| Results of Testing/Procedures |
| Progress Toward Discharge |
Progress notes should be easy for others to read. To ensure quality of progress noting do the following:
| Record notes in black ink |
| Write legibly |
Each discipline writes the following:
| Date, time (including a.m. or p.m.) |
|
|
Each discipline signs his/her legal (employee roster) name followed by his/her license initials/degree initials/hospital staff title as appropriate.
To access rules for documenting in the patient chart, see Medical Record Documentation.
Teacher Progress Notes - Adolescents
Teacher Progress Notes - Children
Teacher's Weekly Progress/Feedback for Subacute Adolescent Services
Related to regulatory standards
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
