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Understanding progress notes
Progress notes are the best way to record every point of communication between you and your client and pave the way for the highest level of care. Although legally required, clinical progress notes are an excellent way to summarize valuable insight from your patient’s progress in a way that other healthcare professionals can easily interpret. Any healthcare provider will assess and review your notes and apply your understanding to further patient treatment. Cool, right?
With millions of US healthcare professionals and providers using progress notes in their practice, they’re a prevalent and accessible practice to incorporate into your clinic. Almost every existing healthcare business integrates progress notes of some sort in their day-to-day, meaning that you absolutely can, and should, too. They’re a highly flexible format that attends to your healthcare needs and provides the best care for your patients.
Importance of progress notes in successful healthcare businesses
Progress notes are a vital component and driver to success in any healthcare business. They offer a variety of essential features, including:
Compliance - Businesses that use progress notes comply with legal, regulatory, and policy laws, as progress notes are required for clinical record-keeping. For example, if a patient has an injury from an accident, their insurance company needs evidence of the damage and updates to ensure reimbursement is correctly applied.
Efficiency - Medical progress notes mean information about a patient’s current health status can be summarized in a way that is easy to read and interpret by other healthcare professionals. This is especially important when information needs to be reviewed, audited, or evaluated.
Continuity of care - Patients who visit other healthcare providers or clinics can receive the same level of quality of care, as the stored progress notes can inform any professional of exactly where they’re at in regard to their progress.
Communication - Progress notes are a document of communication, as they outline every interaction between a practitioner and their patient, which is highly useful for everyone to be on the same page.
They’re also essential for healthcare businesses that incorporate them into their platforms, amongst other features like video conferencing and appointment scheduling software.
Progress notes toolkit: Tips for writing professional progress notes
For the most effective progress notes, be sure to incorporate the following tips and tricks:
Make sure you have the right person - It can be straightforward to mix up people; for instance, multiple individuals could have the same name! Remember to write based on their identifier, checking their date of birth as well as their name.
Use blue or black pen - These colors are preferred for legal documents as they photocopy well. Avoid using colors as they make content difficult to read!
Write neatly - Because other healthcare professionals are likely to read your notes, your notes need to be straightforward to understand.
Put the time and date - Notes should be as accurate as possible, and this is an essential component to include
Sign your note - This way; healthcare professionals know exactly who saw the patient.
Don’t use whiteout - If you make a mistake, which we all do, just rule a line and sign and date the error.
Use professional language - This means no abbreviations or slang, with correct grammar and spelling.
Avoid blank spaces - This way, no one can insert information after it has been documented.
Clarify if your notes are more than one page - So you can avoid others missing essential details.
What not to do while writing progress notes?
While writing progress notes, there are some essential things to keep in mind to ensure you don’t miss critical information or provide incorrect information. To summarize, here's also a helpful video that outlines tips you should avoid!
Avoid using jargon - Jargon can be challenging to understand, and progress notes must be clear to everyone who reads them.
Never assume - Progress notes should be a relatively objective process, with judgments based on medical testing and evaluation. Do not make assumptions about patients, limiting your thinking and limiting solutions to healthcare goals.
Don’t provide unnecessary information - Progress notes can be a tedious process and take time, so make sure you only include what is relevant to the patient and their treatment. They should be concise and to the point.
Don’t keep illegible notes - If you handwrite your notes, they must be legible. Keep them super clear, as this also builds trust between other healthcare professionals if your ideas and reasoning are very easily understood. Over 40,000 people pass away every year due to preventable deaths, led in part because of poor handwriting. So, it is advised that, if possible, you keep typed electronic notes that ultimately minimize this risk.
Avoid flowery language - Keep it simple! Because other healthcare professionals and providers need to review your information and notes, the language should be professional without complex wording. This is to avoid any misinterpretations of information and means anyone can quickly understand your line of thinking.
Never use shortcuts - Always include the time, date, and patient information, despite how long it takes you. The additional time is always worth it in the case that your progress notes are needed for review by a standards committee.
Don’t summarize for critical patients - Sometimes, full details, even the occasional unnecessary ones, are essential to ensure the entire picture is given. For patients in compromising situations, full details are vital. For example, suicidal patients that attempt or commit suicide may have legal cases where reasoning and considered therapy evidence are required.
Never shorthand - While it’s OK to use standard universal medical shorthand methods, remember that others will be reviewing your notes. This means that codes that are easy for you to understand can be complicated for others. It’s best to avoid this problem by not using shorthand at all.
Don’t tamper with evidence - Not only is this a legal problem and could have serious repercussions, but this can result in inaccuracies, misrepresentation, and misconstrued information, especially if the tampering has taken place after notes have been finalized, as this could cause serious confusion amongst healthcare professionals and providers.
A bad example of a progress note section that is unnecessarily long, with jargon, and contains assumptions:
Jane was kicking up a fuss because her friend Emily took her shirt without asking. Emily usually doesn’t do things like that, so it seems out of pocket for Jane to make a big deal out of this. Jane began weeping and crying and kept adamantly claiming that Emily was the culprit, and that ‘this was the last straw,’ and that she would get her revenge. Emily remained silent before walking out of the room. Jane continued crying and left after calming down a bit.
Progress note examples
To guide you, here some excellent examples of sample medical progress notes:
Example #1
Subjective
Sasha states that she doesn’t feel appreciated in the workplace and that “no one talks to me, and whenever I finish work, they just give me more without any positive feedback. It can be very demoralizing.” She elaborates that it is affecting her mood and that she feels “miserable quite often, and I just feel low during the day.”
Objective
Sasha has a flat expression and is slumped in her chair. She presents low symptoms and indicates low self-esteem from her workplace that are beginning to impair her days.
Assessment
This is Sasha’s second session, and she needs to develop ways to communicate her feelings to her work and close friends and family. Failure to act will most likely result in increased depressive feelings for Sasha. She also needs techniques to encourage productivity and mood regulation.
Plan
Sasha will attend further sessions, and we have conducted a plan to work on her productivity and ways to problem-solve at work. If symptoms do not improve within the next two weeks, additional treatment and reevaluation will be discussed concerning a therapist or psychologist.
Example #2
Subjective
Lisa has had trouble sleeping, stating she gets ‘3 hours a night.’ She finds herself thinking a lot and struggling to ‘drift off.’
Objective
Her sleeping patterns have been disrupted as indicated by her sleep track app. She wakes up on average 10 times a night and stays up for considerate periods.
Assessment
Lisa has been provided with breathing techniques, which could be improved.
Plan
The client will see me next Thursday, and we will work on her breathing techniques. Additionally, I have recommended to the client tea and sleep products that contain calming properties. All electronics must be out of use by 9 pm.
Example #3
Subjective
The client states there is a clear pain in her joints, with her hands ‘particularly difficult to move.’ The client states that ‘it is difficult to sew and knit’, which is especially troubling as it is their favorite hobby to do.
Objective
Hand exercises highlighted limited mobility, with a 2cm difference in the right hand compared to the left hand.
Assessment
The client demonstrates symptoms of mild to moderate arthritis. The client would benefit from hand exercises targeting problem areas, with the goal of increasing movement.
Plan
The client has been provided with multiple hand exercises for now and has been referred to extensive hand physical therapists.
Example #4
Subjective
Lucas appears jittery. While sitting in his seat, his knee is continuously jumping and he is twiddling his thumbs. Lucas states that ‘it is getting harder to control anxious thoughts.’
Objective
Lucas demonstrates moderate symptoms of anxiety, with an obvious difficulty in concentrating during the session.
Assessment
Lucas’ anxiety has increased since his last session, and so would benefit from further support. He meets the criteria for GAD.
Plan
Lucas has been provided with some breathing techniques, in addition to being prescribed anti-anxiety medication to be used as a ‘safety net’ for when levels are out of coping scope.
Example #5
Subjective
Mia states that her voice has been ‘fading at work,’ with it attracting notice from colleagues. She feels ‘self-conscious’ about her voice, despite using her semi-occluded vocal tract straw (SOVT) 5 times a day for 5 minutes.
Objective
Mia conducted several SOVT exercises and achieved average to good voicing in 3.5/5 opportunities.
Assessment
The client worked on CTT techniques to increase optimal voicing and to meet functional phrasing demands.
Plan
Continue with the current plan, however, increase CTT exercises with additional strategies to meet optimal voicing across opportunities.
Example #6
Subjective
The patient experienced less cervical pain following previous treatment, with increased neck rotational movement to look right.
Objective
US: 100% 1.5w/cm2, 1Mhz x 7′ to R UT, rhomboids, LS mm.
Assessment
Improving conditions with decreased pain, and is able to do exercises with considerably less pain. No pain medication is required.
Plan
Continue with the plan 3x a week, and see me fortnightly for sessions.
Example #7
Subjective
Tom states that “I do so much work for them, and they never notice me. They never praise or verbally appreciate me in any capacity, and honestly, it really riles me up.”
Objective
He has a tense posture, with clenched fists. Tom took a few minutes to sit down today, preferring to fidget while pacing around the room.
Assessment
Tom appears stressed, and could benefit from some management techniques.
Plan
Tom has been provided with breathing techniques and conflict resolution scenarios. His goal is to take a break outside or in a spare conference room at work when feeling overwhelmed. Tom will see me next Friday.
Example #8
Subjective
The patient came in with stomach pains, stating that the pain level was 8/10.
Objective
The patient is in a curled position, with perspiration on the forehead, and flushed cheeks. Clear discomfort. No pain medication was taken.
Assessment
Bloods were taken, in addition to vitals. All sufficient. Ibuprofen and Panadol were prescribed for pain. Monitored, with pain decreasing.
Plan
Patient took pain medication which alleviated cramps. Patient was advised to monitor symptoms over the next 24 hours. No further treatment needed at this stage.
Example #9
Subjective
Patient reports difficulty sleeping due to right bicep shoulder pain.
Objective
The left scapula is abducted, but right lacks full upward rotation on active shoulder flexion.
Assessment
The patient had an increased ability to reach overhead with a 4kg weight, however, impingement should be prioritized.
Plan
Resistance bands given for standing exercises to increase mobility in the shoulder. Pain medication was prescribed for pain, and the patient will meet with me next Monday.
Example #10
Subjective
Emma has difficulty with her walk, and struggles to be on her feet for ‘more than 30 minutes.’
Objective
120 flexion of the left knee, with 0 extension, and a 70% quad contraction.
Assessment
Emma was advised on proper walker placement and sequencing techniques with knee exercises given.
Plan
Emma will meet with me next Tuesday, and will focus on strengthening and increasing the mobility of her knee through the exercises given. Pain medication was prescribed for the pain.
Final thoughts
Progress notes are a relatively simple practice to begin incorporating into your healthcare practice. However, there are essential learning processes that you must get right to ensure legal compliance and to create practical notes that can be easily understood. Carepatron is a company that provides clinical tools for healthcare businesses, and they can quickly get you started to ensure you don’t miss any critical parts of progress notes. But whatever you decide, make sure to spend time reviewing what goes into a progress note to make sure you’re providing the highest level of care for your patients.
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