From the Guidelines
To create effective progress notes for a patient, I recommend using the SOAP format (Subjective, Objective, Assessment, Plan) as it is the most structured and efficient method, supported by the American College of Physicians 1, 2, 3, 4, 5, 6.
Key Components of Progress Notes
- Begin each note with the date and time clearly marked at the top.
- For the Subjective section, document the patient's reported symptoms, concerns, and any changes since the last visit.
- In the Objective section, record vital signs, physical examination findings, and results of any tests or procedures performed.
- The Assessment section should include your clinical impression, diagnosis, or differential diagnoses based on the gathered information.
- Finally, in the Plan section, detail the treatment approach including specific medications (with names, dosages, frequency, and duration), ordered tests, referrals, and follow-up instructions.
Importance of Clarity and Organization
Be sure to sign each note with your name, credentials, and contact information. This structured approach ensures comprehensive documentation while maintaining clarity and organization, which is essential for continuity of care and medical-legal purposes. The SOAP format is particularly effective because it separates factual observations from clinical interpretations, making your clinical reasoning transparent to other healthcare providers who may review the record.
Avoiding Common Pitfalls
Avoid the misuse of documentation techniques such as copy/paste, which can lead to factual errors and compromise patient safety 2, 3, 6. Instead, use electronic health records to improve the accuracy, completeness, and efficiency of documentation by leveraging capabilities such as templates and drop-down boxes, while ensuring that all documentation is accurate, up-to-date, and relevant to the patient's current condition.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Progress Notes
To create a progress note for a patient, the following information should be included:
- Date of the progress note
- Patient's current condition and any changes since the last progress note
- Medications the patient is currently taking, including lisinopril
- Blood pressure readings and any changes since the last progress note
- Any side effects or adverse reactions to medications
Lisinopril Treatment
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and congestive heart failure 7, 8, 9. The medication works by decreasing total peripheral resistance, maintaining or improving cardiac contractility, and promoting regression of left ventricular hypertrophy 7.
Dosage and Administration
The dosage of lisinopril varies depending on the patient's condition and response to treatment. Studies have shown that once-daily lisinopril is effective in lowering blood pressure in patients with mild to moderate hypertension 7, 9, 10. The starting dose for elderly patients is 5 mg, increasing to a maximum of 40 mg once daily as required 10.
Predicting Response to Lisinopril
A pilot study found that clinical and metabolite markers, such as BMI, GFR, and 2-oxoglutarate, can predict response to lisinopril 11. However, further validation cohorts are needed to confirm the predictive values of these markers.
Monitoring and Follow-up
Regular monitoring of blood pressure and follow-up appointments are necessary to assess the patient's response to lisinopril and adjust the treatment plan as needed.