Progress note template
The daily inpatient note, in SOAP order.
- Overnight events
- Escalations, events, observations since the last review.
- Symptoms today
- As reported.
- Examination
- Vitals, then by system.
- Investigations
- Results back since the last note.
- Impression
- Where the course has reached.
- Plan
- Changes, new orders, planned discharge date.
Worked examples
Progress note · day 3 of an admission Bennett, Joyce · 74F · Synthetic patient
Overnight events Nil escalations. Oxygen weaned to room air at 04:00. Symptoms today Cough settling, no fevers overnight, mobilising with a stick. Examination T 36.8, HR 78, BP 132/78, RR 18, SpO2 96% RA. R basal creps. Investigations CRP 41, down from 180 on admission. White cells normalised. Impression CAP day 3, responding to IV antibiotics. Plan Switch to PO amoxicillin 1 g TDS. Physiotherapy review. Discharge Thursday if the trend holds.
Progress note · day 2 of diuresis Fitzgerald, Noel · 81M · Synthetic patient
Overnight events UO 2.1 L. One episode of postural dizziness on standing at 06:00. Symptoms today Breathing easier lying flat, still short of breath walking to the bathroom. Examination Weight down 1.8 kg from admission. JVP 3 cm. Oedema to the ankle. Chest clear at the bases. Investigations Cr 156 (142). K 3.4. Mg 0.72. Impression Responding to diuresis. Rising Cr, falling K. Plan Furosemide 80 mg BD to 40 mg BD. PO KCl and Mg replacement. EUC and Mg tomorrow. Withhold perindopril today.
