Do you write progress notes?

Writing Progress Notes in Clinical Documentation

I do not write progress notes as I am an AI medical consultant, but I can provide comprehensive guidance on how healthcare providers should write effective progress notes based on established clinical guidelines.

Structure and Purpose of Progress Notes

Progress notes serve as the primary documentation method for patient care and are essential for:

• Communicating patient status and care plans among healthcare team members
• Creating a legal record of care provided
• Supporting clinical decision-making
• Facilitating quality assessment and reporting

According to the American College of Physicians, progress notes should follow a structured format that supports clinicians' cognitive processes during documentation 1. The most widely recommended format is the SOAP structure:

• Subjective: Patient's history, complaints, and symptoms
• Objective: Vital signs, examination findings, test results
• Assessment: Clinical impressions and diagnoses
• Plan: Treatment plans and next steps

Best Practices for Progress Note Documentation

Content Guidelines

1. Patient Narrative: The note should include the patient's story in sufficient detail to accurately represent their condition 1

2. Structured Data: Capture structured data only where useful for care delivery or essential for quality assessment 1

3. Longitudinal Care: Documentation should support care delivery over time and across venues 1

4. Appropriate Use of Templates: When used appropriately, macros and templates can improve completeness and efficiency, particularly for standardized elements like review of systems 1

Documentation Quality

The American College of Physicians recommends avoiding common documentation pitfalls 2:

• Poor organization
• Excessive copy/paste creating verbose notes
• Vague assessments
• Inadequate plans
• Excessive abbreviations
• Delayed documentation

Copy/Forward Functionality

While the "review/edit/attest, then copy/forward" approach can improve efficiency, it must be used judiciously 1:

• 90% of physicians use copy and paste functionality when writing electronic notes 3
• 71% of physicians recognize that inconsistencies and outdated information are more common in notes with copied text 3
• Only properly reviewed and still-accurate information should be copied forward

Documentation in Team-Based Care

Progress notes should reflect the collaborative nature of modern healthcare:

• Notes should integrate information from multiple providers 1
• Documentation should support care coordination across the healthcare team 1
• For patients with complex conditions, notes should document progress toward treatment goals and medication compliance 2

Documentation for Special Circumstances

Advance Care Planning

Progress notes should document discussions about advance care planning:

• Document patient preferences regarding end-of-life care 1
• Include references to advance directives when completed 1
• Note any resources provided to patients for advance care planning 1

Patient-Centered Documentation

The American College of Physicians notes that patient access to progress notes may improve engagement and quality of care 1:

• Consider that patients may read notes when documenting
• Use respectful, clear language
• Avoid jargon when possible

Avoiding Common Pitfalls

1. Note Bloat: Avoid excessive information that distracts from diagnoses and treatment plans 4

2. Documentation Burden: Focus on essential information rather than collecting data primarily for third parties 1

3. Inconsistent Information: Ensure information is consistent across the record 3

4. Delayed Documentation: Document care in a timely manner 2

Progress notes should ultimately serve as a concise vehicle of communication about a patient's condition, being readable, easily understood, complete, accurate, and concise 5. By following these guidelines, healthcare providers can create high-quality documentation that supports optimal patient care.