What Are Some Guidelines for Writing Patient Progress Notes?

What Are Some Guidelines for Writing Patient Progress Notes?

When writing patient progress notes, document issues relevant to acute medical problems, document the patient's vitals, state the working diagnosis, and list tests, treatment plans and therapies, recommends University of Florida Health. For patients with multiple medical problems, number each diagnosis separately.

List daily weights, fluid balance, drain outputs and other monitor settings, recommends University of Florida Health. Give a brief description of the general condition of the patient and exam results of the heart, lungs and abdomen. Include lab findings, level of pain and any new medical complaints. If the working diagnosis is uncertain, indicate the most likely diagnosis.