# 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.

<!--
Guidance: How to use this template
- Write what changed since the last note; do not copy forward old text.
- Keep the assessment and plan problem-based so the next clinician can
  see what is active and what is resolved.
- Time the note when it is written, and add a timed addendum for later
  events rather than editing the original.
-->

| 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

<!-- Guidance: Overnight events, symptoms, patient concerns, nursing and allied health reports since the last note. -->

[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]
- [System]: [Findings]
- [System]: [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.]

1. [Problem 1]: [Status and interpretation]
2. [Problem 2]: [Status]
3. [Problem 3]: [Status]

## 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.