Progress note
Encyclopedia
Progress Notes are the part of a medical record
where healthcare professionals record details to document a patient
's clinical status or achievements during the course of a hospital
ization or over the course of outpatient care. Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. A very common format is the SOAP note
, where the note is organized into Subjective,
Objective, Assessment, and Plan sections. Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physician
s and nurses to document patient care on a regular interval during a patient's hospitalization.
Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other members of the medical care team, and allow retrospective review of case details for a variety of interested parties. They are the repository of medical facts and clinical thinking, and are intended to be a concise vehicle of communication about a patient’s condition to those who access the health record. The majority of the medical record consists of progress notes documenting the care delivered and the clinical events relevant to diagnosis
and treatment for a patient. They should be readable, easily understood, complete, accurate, and concise. They must also be flexible enough to logically convey to others what happened during an encounter, e.g., the chain of events during the visit, as well as guaranteeing full accountability for documented material, e.g., who recorded the information and when it was recorded.
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing
purposes. Nurses are required to generate progress notes on a more frequent bases, depending on the level of critical care
notes may be required anywhere from several times an hour to several times a day.
clarity has contributed to the noisy structure of progress notes. A progress note is considered as containing noise when there is difference between the surface form
of the entered text and the intended content. For instance, when a clinician enters "blodd presure" or "bp" instead of "blood pressure", or an acronym such as "ARF" that could mean "Acute Renal Failure" or "Acute Rheumatic Fever". The more noise clinicians introduce in their progress notes, the less intelligible the notes will become. Some of the common types of noise are abbreviation, misspelling and punctuation error.
There is a growing interest within the medical informatics and noisy text analytics
communities to research for ways to clean and remove noise from progress notes. This real-time progress note cleaning system for example cleans progress notes in real-time as they are being entered.
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
where healthcare professionals record details to document a patient
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
's clinical status or achievements during the course of a hospital
Hospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
ization or over the course of outpatient care. Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. A very common format is the SOAP note
SOAP note
The SOAP note is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note...
, where the note is organized into Subjective,
Objective, Assessment, and Plan sections. Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s and nurses to document patient care on a regular interval during a patient's hospitalization.
Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other members of the medical care team, and allow retrospective review of case details for a variety of interested parties. They are the repository of medical facts and clinical thinking, and are intended to be a concise vehicle of communication about a patient’s condition to those who access the health record. The majority of the medical record consists of progress notes documenting the care delivered and the clinical events relevant to diagnosis
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
and treatment for a patient. They should be readable, easily understood, complete, accurate, and concise. They must also be flexible enough to logically convey to others what happened during an encounter, e.g., the chain of events during the visit, as well as guaranteeing full accountability for documented material, e.g., who recorded the information and when it was recorded.
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing
Invoice
An invoice or bill is a commercial document issued by a seller to the buyer, indicating the products, quantities, and agreed prices for products or services the seller has provided the buyer. An invoice indicates the buyer must pay the seller, according to the payment terms...
purposes. Nurses are required to generate progress notes on a more frequent bases, depending on the level of critical care
Critical care
Critical care may refer to:* Critical care medicine or intensive-care medicine, a branch of medicine concerned with life support for critically ill patients* "Critical Care" , an episode of the TV series...
notes may be required anywhere from several times an hour to several times a day.
Noise in Progress Notes
The urge amongst clinicians for faster text entry while attempting to retain semanticclarity has contributed to the noisy structure of progress notes. A progress note is considered as containing noise when there is difference between the surface form
of the entered text and the intended content. For instance, when a clinician enters "blodd presure" or "bp" instead of "blood pressure", or an acronym such as "ARF" that could mean "Acute Renal Failure" or "Acute Rheumatic Fever". The more noise clinicians introduce in their progress notes, the less intelligible the notes will become. Some of the common types of noise are abbreviation, misspelling and punctuation error.
There is a growing interest within the medical informatics and noisy text analytics
Noisy text analytics
Noisy text analytics is a process of information extraction whose goal is to automatically extract structured or semistructured information from noisy unstructured text data...
communities to research for ways to clean and remove noise from progress notes. This real-time progress note cleaning system for example cleans progress notes in real-time as they are being entered.