What are clinical progress notes?


Quick Answer

Health care professionals use clinical progress notes to document the development of treatment and patient condition after every clinical session, reports Farlex. A physician, nurse, social worker or physical therapist may use such notes.

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Full Answer

Depending on the objectives of such notes, they may serve a variety of purposes, explains Farlex. For a physician, such notes are likely to be problem-centered, addressing medical issues relating to therapeutic elements of the patient's condition. A nurse's notes often focus more specifically on nursing care, addressing responses to specific medications, abilities of patient to do tasks associated with self-care and comprehension of a particular condition, treatment or situation. Hospitals are more likely to use progress notes than a clinic, which only takes progress notes during or after visits.

Psychotherapists use progress notes to keep track of clinical assessments, interventions and results from treatments, according to Martha St. Enterprises. Notes also provide a record that the therapist is following proper standards and using the correct treatments. Progress notes allow therapists to review the past history of a patient's case to adjust treatment as necessary. Other clinicians can also use notes to catch up on cases that they are observing or that have been transferred to them. Progress notes also document communication between clinicians.

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