A Progress note template is used by healthcare professionals to record the details of the clinical status of a patient. This helps the doctors to reassess the data and recovery graph of the patient.
There are different formats of progress note templates available. However, the detail present on the progress note depends on the details in hand and the important information to record.
Using progress note templates, the physicians record the information about patients’ health status and use it to compare with the past status. So, the best plans for the treatment can be made based on the findings of this comparison. Therefore, these notes are written on a regular interval during a patient is hospitalized.
Progress note template is really helpful as it acts to provide medical facts in the best communication media about the medical condition of any patient for medical experts.
Most of the hospital records include progress notes of the patients as proof of best care has been provided to the patients based on the diagnosis. Therefore, the use of progress note templates helps to develop a proper system to manage the progress notes. Moreover, the easier to understand, effective and accurate progress note can be created using the template.
The progress note template allows recording complete information of every encounter with the transparency and accountability of the material. You can also see doctor prescription pad template.
Types of Progress Note Template
There are different types of progress note templates used by medical physicians and nurses. It depends on the information available and necessary to record. Moreover, the most common types of progress note templates are the SOAP note template and the DART system template.
The SOAP stands for Subjective, Objective, Assessment and Plan. What the patient share with the doctor is known as subjective. While the objective is determined by physical examination, and lab tests. Moreover, the assessment is the diagnosis provided by the doctor to plan the treatment accordingly.
Another type of progress note template is the DART system. It stands for Description, Assessment, Response, and Treatment. The proper documentation of the diagnosis, examination, and treatment is a very important part of the process. You should also check Fake Doctor’s Note Templates.
Elements of Progress Note Template
There are several components of the progress note template. It depends on the information required to be recorded by the health professional. The following details must be included in the progress note template:
- Name of the Patient
- Date of Birth
- Patient No.
- Name of the Doctor
- Progress Notes
- Next Appointment
- Review Date
- Treatment Plan
- Signature and Date
Do’s and Don’ts of Progress Note Template
There are several guidelines to carefully follow while creating a progress note template. Following are the dos and don’ts of creating progress note:
- Be Concise
- Include All Details
- Carefully describe the Treatment
- Write legibly
- Take care of the Patient Privacy
- Document the Responses of the others
- Clearly explain the reason for disregarding consultant advice.
- Never type disrespectful about a patient.
The progress note template can be created using MS excel and word for print friendly nature and easy customization.