Progress notes
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The document provides information on progress notes including: - Progress notes are used to document a patient's clinical status and progress over time during hospitalization or outpatient care. - They serve to communicate findings between healthcare professionals and allow retrospective review of a patient's case. - Progress notes are intended to be concise and provide communication about a patient's condition to those accessing their health record. Physicians and nurses are generally required to generate progress notes on a regular basis.
Progress notes
- 1. Progress notes Dr HP Singh Professor & Head
- 2. Outlines • Definition • Relevance • Schematic representation • Case scenario
- 3. Clinical notes Opening notes Narrative notes Progress notes includes A. Demographic Information B. Chief Complaint C. Symptomatology D. History time based notes to show the chronology of events PAIP SOAP HSOAP •History +SOAP
- 4. • Etymology: L, progredi + nota • 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 • 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 DEFINITION
- 5. • intended to be a concise vehicle of communication about a patient’s condition to those who access the health record • Physicians are generally required to generate at least one progress note for each patient encounter • 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. .
- 6. Daily progress note serves as a written medical legal document to • Serve as a record of a patient’s hospitalization • be completed on a Daily basis and includes all “events” that occur during the hospitalization • Record “events” in terms of subjective and objective findings
- 7. • include new and active patient health/social issues (“problems”) • to evaluate/assess each problem and to formulate an appropriate • be legible and well written so to avoid any misunderstanding by the reader • have a time and date and be signed on each page by the author in legible fashion
- 8. Purpose of progress notes: • To inform research • To act as a working document for day-today recording of patient care • To store a chronological account of the patient’s life, illnesses, its context and who did what and to what effect • To enable the clinician to communicate with him- or herself • To allow continuity of approach in a continuing illness RELEVANCE
- 9. • To record any special factors that appear to affect the patient or the patient’s response to treatment • To record any factors that might render the patient more vulnerable to an adverse reaction to management or treatment • To record risk assessments to protect the patient and others • To record the advice given to general practitioners, other clinicians and other agencies • To record conversations with other clinicians for collaboration, consultation or to help facilitate referrals
- 10. • To record the information received from others, including carers • To store a record to which the patient may have access • To inform medico-legal investigations • To inform clinical audit, governance and accreditation • To allow contributions to national data-sets, morbidity registers • in a multidisciplinary treatment setting, notes offer different clinicians a way to stay informed based on the observations and interventions of other clinicians
- 11. • To record the information received from others, including carers • To store a record to which the patient may have access • To inform medico-legal investigations • To inform clinical audit, governance and accreditation • To allow contributions to national data-sets, morbidity registers • in a multidisciplinary treatment setting, notes offer different clinicians a way to stay informed based on the observations and interventions of other clinicians
- 12. Problem oriented record keeping is cornerstone of problem-oriented medical practice and consists of • Establishment and use of data base • Formulation and maintenance of problem list • A plan for management of problem • Education of the patient • Establishment and maintenance of some form of audit
- 13. Data base The result of registration in the medical record of a defined store of information pertinent to the patient and his/her problems Components Presenting problems Patient profile Present illness(es) Past history Previous illness Systems review Family history Physical examination Growth charts Developmental flow sheet or screening tests Defined baseline lab data
- 14. Once the initial data has been recorded, further data are recorded in relation to specific ,named and numbered problems The number of the problem is entered in left hand margin and the name of the problem is the first part of the entry
- 15. Problem list • Derived from information obtained from the data base • It includes – Medical – Social – Developmental – Psychologic – Economic – Environmental – Nutritional • An essential feature of the problem list is that it remains intellectually honest i.e., each problem should be expressed only at the level of understanding or confidence which can be substantiated by objective evidence • It helps to avoid jumping to potentially erroneous diagnostic conclusions
- 16. PAIP • To be used at the end of opening notes • Shorter than opening or narrative notes P - Problem A - Assessment I - Intervention P - Plan
- 17. SOAP • a method of documentation employed by health care providers to write out notes in a patient‘s chart, along with other formats • Most commonly used progress note • More focussed than complete history and physical documentation • Limited to what is pertinent to current problem(s) Components Subjective Objective Assessment Plan
- 18. Subjective Record of subjective findings that occurred during the evening , overnight, and in the morning that patient is being examined Essentially how the patient felt during the evening, night time and morning hours and what happened during those hours Usually recorded in two paragraphs First paragraph addresses chief concerns or complaints. If this is the first time a physician is seeing a patient, the physician will take a History of Present Illness. Second paragraph includes pertinent portions of past medical history
- 19. Objective Physical Exam: Vital signs, focused physical exam but almost always should include: • RESPIRATORY • CARDIAC • ABDOMINAL • CNS pertinent normal findings and abnormalities Laboratory data Diagnostic Imaging Microbiology a Medication List which includes a listing of all scheduled and PRN (as needed) medications relevant to active problems is recommended but is not required.
- 20. Assessment the most important part of SOAP note begin with a one-sentence summary of the problem should be organized by problems with the newest or most acute problem first For each problem, include Statement of the problem Differentials(acute problem) and present status(chronic problem) Clinical reasoning for and against each differential
- 21. Plan Plan must be formulated to address each problem Includes the following components Diagnostic tests Treatment plan Patient education Planned follow-up
- 22. Master X 2 years of age, from Rewa presented with Subjective Presented with history of continuous fever of one week duration, loose stools without blood or mucus at frequency of 6-7/day. was treated with concentrated ORS and injectable antibiotics. Vomiting started 4 days later with a frequency of 5-6/day. Urine output was adequate. One episode of generalized tonic clonic seizures 12 hour ago followed by altered sensorium for 12 hours. No history of head injury, ear discharge , cyanotic heart disease or seizures Objective Weight 11.5 kg, temperature 39.50 C, pulse rate 100/min, RR 28/min, BP 100/70 mm Hg. Toxic looking semi- conscious. No evidence of dehydration or meningeal irritation. Liver span of 4.5 cm and spleen just palpable. Brisk DTR, no sustained clonus with bilateral extensor planters but no focal neurological signs. Normal fundus examination, no neuro –cutaneous markers. CASE SCENARIO
- 23. Assessment Enteric fever with encephalopathy Prolonged continuous fever with diarrhea, splenomegaly and altered sensorium. Presence of seizures in first week unlikely. Pyogenic meningitis No signs of meningeal irritation, long history against this possibility Hypernatremic dehydration Use of Concentrated ORS and presence of seizures support the possibility. Dehydration may be delayed. Splenomegaly and fever of 39.50 C can not be explained Brain abscess Absence of focal neurological signs and lack of predisposing factors against this possibility
- 24. Plan Diagnostic tests – Complete hemogram – Serum lytes – Blood glucose – LFT – Stool examination – Widal test – Blood culture – CSF examination – Neuro-imaging • Treatment plan – Intravenous fluids – Injectable appropriate antibiotics – Antipyretics – anticonvulsants
- 25. Plan con’t…. Education – Prognosis explained to family members Planned follow-up – Review vital signs and lab reports at 9.30 am
- 27. Progress notes in NICU • Essentially the same scheme albeit some minor modifications • F-IMNCI recommends the following T – temperature A – airway B – breathing C – circulation F – fluids M – medications F – feeding M – monitoring C – communication F – follow-up
- 28. An FTNV newborn with no significant ante-natal history has not cried, is deeply comatosed, limp with all extremities extended, had one episode of multifocal seizures. A provisional diagnosis of HIE stage III was made. Ventilatory support was needed as he had irregular respiratory pattern and was not able to maintain adequate SaO2 on supplemental oxygen. His clinical condition deteriorated all of a sudden while on mechanical ventilation. CASE SCENARIO
- 30. Comatosed, no seizures , AF at level, fixed mid dilated pupil Tone – flaccid Neonatal reflexes – absent Abdomen soft , no organomegaly No icterus, purpura, petechie, bleeding from any site On intravenous fluid (D10%) 50 ml tid Injectable antibiotics, Inj. Ca. gluconate Anticonvulsants, dopamine NPO Monitor vitals, SaO2 weight gain Watch for seizure activity, abrupt changes in BP,HR, SaO2 Monitor urine output Watch for bleeding, icterus
- 31. Complete blood count Sepsis screen BUN, Sr. creatinine, urinary ᵦ-2-microglobulin LFT, Blood sugar Sr. lytes cTNI,cTNT,CK-MB ABG DWI,MRS,EEG Prognosis explained Review with lab reports at 10.00am or when needed
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