Progress note

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 hospitalization or over the course of outpatient care.[1] 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. One example is the SOAP note, where the note is organized into Subjective, Objective, Assessment, and Plan sections. Another example is the DART system, organized into Description, Assessment, Response, and Treatment.[2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians 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. [3][4][5][6][7]

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 basis, depending on the level of care and 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 semantic 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 "blood pressure" 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 errors.

References

1. "UW Internal Medicine Residency Program". Retrieved 2009-04-10.
2. "Records and Progress Notes" (PDF). Retrieved 2013-02-24.
3. R.Dick, E. Steen (Editors): The Computer Based Patient Record. Washington DC, National Academy Press,1991.
4. A.L. Rector, A.J. Glowinski, W.A. Nowlan, A. Rossi-Mori: Medical Concept Models and Medical Records: An approach based on GALEN and PEN&PAD. JAMIA, 1995, 2, 19-35.
5. E. Nygren, P. Henriksson: Reading the Medical Record I. Analysis of physician's ways of reading the medical record. Yearbook of Medical Informatics, 1994, Schattauer, Germany.
6. S.M. Huff, R.A. Rocha, B.E. Bray, H. Warner, P.J. Haug: An event Model for Medical Information Representation. JAMIA, 1995, 2, p 116-134.
7. L. Weed: "The Problem Oriented Record as a Basic Tool in Medical Education, Patient Care, and Research." Ann. Clin. Res., 1971, 3, (3).