How to Write Progress Notes: Ultimate Guide for 2023

Progress notes are written documentation of a patient’s medical treatment and care. They typically include information about the patient’s condition, treatment plan, and any changes or updates to their care. Progress notes are typically written by doctors or other healthcare providers, and are used to keep track of a patient’s progress over time and to communicate with other members of the healthcare team. They are an important part of the medical record and can help ensure that patients receive high-quality, coordinated care.

7/1/20

• Patient presents with complaints of abdominal pain and bloating
• Physical exam reveals tenderness in the abdomen and mild swelling
• Prescribed antacid medication and advised to avoid certain trigger foods

7/8/20

• Patient reports improvement in symptoms and decreased bloating
• Continued with current medication regimen and added probiotics
• Scheduled follow-up appointment in two weeks

7/22/20

• Patient reports continued improvement in symptoms
• Discussed potential food allergies and recommended allergy testing
• Scheduled follow-up appointment in one month

8/22/20

• Allergy testing revealed sensitivity to gluten and dairy
• Patient reports increased energy and decreased abdominal pain since starting a gluten and dairy-free diet
• Continued with current medication regimen and discussed strategies for maintaining a healthy diet
• Scheduled follow-up appointment in three months for diet and symptom management.

Progress Notes: Sample 2

• Date: 11/15/20
• Time: 11:00am
• Patient: Jane Doe
• Reason for visit: Follow-up appointment
• Progress: Jane continues to show improvement in her symptoms. She reports less frequent headaches and improved energy levels. She has been consistently taking her medication and attending therapy sessions. Her mood remains stable and she is engaging well in daily activities.
• Plan: Continue current treatment plan and schedule a follow-up appointment in two weeks.
• Date: 11/17/20
• Time: 3:00pm
• Patient: John Smith
• Reason for visit: New patient intake
• Progress: John appeared to be in good health during the initial examination. He reported some occasional muscle stiffness and fatigue, but no significant issues. He was educated on the importance of regular exercise and a healthy diet.
• Plan: Recommend a physical therapy referral for the muscle stiffness and schedule a follow-up appointment in one month.
• Date: 11/19/20
• Time: 9:00am
• Patient: Emily Johnson
• Reason for visit: Follow-up for chronic pain
• Progress: Emily continues to experience chronic pain in her lower back and legs. She has been trying various pain management techniques, but reports limited success. She is struggling with daily activities and reports increased levels of anxiety and depression.
• Plan: Increase medication dosage and refer to a pain specialist for further evaluation and treatment options. Schedule a follow-up appointment in two weeks to assess progress.