Progress Note Template

Daily progress note: interval history, vitals with trend, exam, results, assessment and plan by problem, signature

SaludBreveprogress noteActualizada 20 oct 2026

Cómo usar: Use for daily inpatient or interval outpatient notes. Write what changed since the last note and keep the plan problem-based. Main pitfall: copying forward old text that no longer reflects the patient.

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Progress Note: [Patient ID placeholder], YYYY-MM-DD HH:MM

Daily or interval progress note for an inpatient or ongoing outpatient episode: what changed since the last note, current findings, results, assessment by problem and plan. Based on common clinical documentation practice. This is a documentation format, not clinical advice. Use placeholders only in this template, and follow local privacy law (for example HIPAA or GDPR) and your institution's documentation policy when completing a real record.

Field	Value
Patient	[Patient name], [MRN / health number]
Date and time	YYYY-MM-DD HH:MM
Day of admission / post-op day	[Day n]
Author	[Name, role]

Interval history

[Events since the last note.] Example: No overnight events. Reports less breathlessness; walked to the bathroom unaided. Eating half of meals. No new pain.

Vital signs

Parameter	Current	Trend (last 24 h)
Temperature	[°C]	[Range]
Heart rate	[bpm]	[Range]
Blood pressure	[mmHg]	[Range]
Respiratory rate	[/min]	[Range]
Oxygen saturation	[% on room air / oxygen]	[Range]
Fluid balance	[In / out, ml]	[Net]

Examination findings

[Focused examination relevant to active problems, with changes since the last examination.]

General: [Findings]
Lines, drains, wounds: [Site, condition, day in place]

Results

Test	Result	Previous	Comment
[Test]	[Value]	[Value]	[Improving / worsening]
[Imaging]	[Key finding]	Not applicable	[Reported by]

Assessment

[One-line summary of the patient and overall direction: improving, stable or deteriorating.]

[Problem 1]: [Status and interpretation]

Plan

Problem	Plan	Owner
[Problem 1]	[Investigations, treatment changes, monitoring]	[Team member]
[Problem 2]	[Plan]	[Team member]
Disposition	[Expected discharge date, criteria, referrals]	[Team]

Discussed with: [patient, family, senior clinician, nurse in charge]. Escalation status: [as documented per local policy].

Signature

[Name], [role], [registration number], YYYY-MM-DD HH:MM.

Standard and licence note

Based on common clinical documentation practice for progress notes. This is a documentation format, not clinical advice; follow local privacy law and your institution's documentation policy. Template licence: MIT.

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