Progress notes

Progress notes

Dr HP SinghProfessor & Head

Outlines

• Definition

• Relevance

• Schematic representation

• Case scenario

Clinical notes

Opening notes Narrative notes Progress notes

includes

A. Demographic Information

B. Chief Complaint

C. Symptomatology

D. History

time based notes

to show the chronology of events

PAIP

SOAP

HSOAP•History +SOAP

• Etymology: L, progredi + nota

• part of a medicalrecord where healthcare professionals record detailsto document a patient's clinical status orachievements during the course of a hospitalizationor over the course of outpatient care

• serve as a record of events during a patient's care,allow clinicians to compare past status to currentstatus, serve to communicate findings, opinions andplans between physicians and other members of themedical care team, and allow retrospective review ofcase details for a variety of interested parties

DEFINITION

• intended to be a concise vehicle ofcommunication about a patient’s condition tothose who access the health record

• Physicians are generally required to generate atleast one progress note for each patientencounter

• Nurses are required to generate progress noteson a more frequent bases, depending on thelevel of critical care notes may be requiredanywhere from several times an hour to severaltimes a day.

.

Daily progress note serves as a written medical legal document to

• Serve as a record of a patient’s hospitalization

• be completed on a Daily basis and includes all “events” that occur during the hospitalization

• Record “events” in terms of subjective and objective findings

• include new and active patient health/social issues (“problems”)

• to evaluate/assess each problem and to formulate an appropriate

• be legible and well written so to avoid any misunderstanding by the reader

• have a time and date and be signed on each page by the author in legible fashion

Purpose of progress notes:

• To inform research

• To act as a working document for day-today recording of patient care

• To store a chronological account of the patient’s life, illnesses, its context and who did what and to what effect

• To enable the clinician to communicate with him-or herself

• To allow continuity of approach in a continuing illness

RELEVANCE

• To record any special factors that appear to affect the patient or the patient’s response to treatment

• To record any factors that might render the patient more vulnerable to an adverse reaction to management or treatment

• To record risk assessments to protect the patient and others

• To record the advice given to general practitioners, other clinicians and other agencies

• To record conversations with other clinicians for collaboration, consultation or to help facilitate referrals

• To record the information received from others, including carers

• To store a record to which the patient may have access

• To inform medico-legal investigations

• To inform clinical audit, governance and accreditation

• To allow contributions to national data-sets, morbidity registers

• in a multidisciplinary treatment setting, notes offer different clinicians a way to stay informed based on the observations and interventions of other clinicians

• To record the information received from others, including carers

• To store a record to which the patient may have access

• To inform medico-legal investigations

• To inform clinical audit, governance and accreditation

• To allow contributions to national data-sets, morbidity registers

• in a multidisciplinary treatment setting, notes offer different clinicians a way to stay informed based on the observations and interventions of other clinicians

Problem oriented record keeping is cornerstone of problem-oriented medical practice and consists of

• Establishment and use of data base

• Formulation and maintenance of problem list

• A plan for management of problem

• Education of the patient

• Establishment and maintenance of some form of audit

Data base The result of registration in the medical record of a

defined store of information pertinent to the patient and his/her problems

ComponentsPresenting problemsPatient profile Present illness(es)Past historyPrevious illnessSystems reviewFamily historyPhysical examinationGrowth chartsDevelopmental flow sheet or screening testsDefined baseline lab data

Once the initial data has been recorded, further data are recorded in relation to specific ,named and numbered problems

The number of the problem is entered in left hand margin and the name of the problem is the first part of the entry

Problem list• Derived from information obtained from the data base• It includes

– Medical– Social– Developmental– Psychologic– Economic– Environmental– Nutritional

• An essential feature of the problem list is that it remains intellectually honest i.e., each problem should be expressed only at the level of understanding or confidence which can be substantiated by objective evidence

• It helps to avoid jumping to potentially erroneous diagnostic conclusions

PAIP

• To be used at the end of opening notes

• Shorter than opening or narrative notes

P - Problem

A - Assessment

I - Intervention

P - Plan

SOAP• a method of documentation employed by health care

providers to write out notes in a patient‘s chart, along with other formats

• Most commonly used progress note

• More focussed than complete history and physical documentation

• Limited to what is pertinent to current problem(s)

Components

Subjective

Objective

Assessment

Plan

Subjective

Record of subjective findings that occurred during the evening , overnight, and in the morning that patient is being examined

Essentially how the patient felt during the evening, night time and morning hours and what happened during those hours

Usually recorded in two paragraphs

First paragraph addresses chief concerns or complaints.If this is the first time a physician is seeing a patient, the physician will take a History of Present Illness. Second paragraph includes pertinent portions of past medical history

Objective

Physical Exam: Vital signs, focused physical exam but almost always should include:

• RESPIRATORY

• CARDIAC

• ABDOMINAL

• CNS

pertinent normal findings and abnormalities

Laboratory data

Diagnostic Imaging

Microbiology

a Medication List which includes a listing of all scheduled and PRN (as needed) medications relevant to active problems is recommended but is not required.

Assessment

the most important part of SOAP note

begin with a one-sentence summary of the problem

should be organized by problems with the newest or most acute problem first

For each problem, include

Statement of the problem

Differentials(acute problem) and present status(chronic problem)

Clinical reasoning for and against each differential

Plan

Plan must be formulated to address each problem

Includes the following components

Diagnostic tests

Treatment plan

Patient education

Planned follow-up

Master X 2 years of age, from Rewa presented with

Subjective

Presented with history of continuous fever of one week duration, loose stools without blood or mucus at frequency of 6-7/day. was treated with concentrated ORS and injectable antibiotics. Vomiting started 4 days later with a frequency of 5-6/day. Urine output was adequate. One episode of generalized tonic clonic seizures 12 hour ago followed by altered sensorium for 12 hours.

No history of head injury, ear discharge , cyanotic heart disease or seizures

Objective

Weight 11.5 kg, temperature 39.50 C, pulse rate 100/min, RR 28/min, BP 100/70 mm Hg. Toxic looking semi- conscious. No evidence of dehydration or meningeal irritation. Liver span of 4.5 cm and spleen just palpable. Brisk DTR, no sustained clonus with bilateral extensor planters but no focal neurological signs. Normal fundus examination, no neuro –cutaneous markers.

CASE SCENARIO

Assessment

Enteric fever with encephalopathy

Prolonged continuous fever with diarrhea, splenomegaly and altered sensorium. Presence of seizures in first week unlikely.

Pyogenic meningitis

No signs of meningeal irritation, long history against this possibility

Hypernatremic dehydration

Use of Concentrated ORS and presence of seizures support the possibility. Dehydration may be delayed. Splenomegaly and fever of 39.50 C can not be explained

Brain abscess

Absence of focal neurological signs and lack of predisposing factors against this possibility

PlanDiagnostic tests

– Complete hemogram

– Serum lytes

– Blood glucose

– LFT

– Stool examination

– Widal test

– Blood culture

– CSF examination

– Neuro-imaging

• Treatment plan– Intravenous fluids

– Injectable appropriate antibiotics

– Antipyretics

– anticonvulsants

Plan con’t….

Education – Prognosis explained to family members

Planned follow-up– Review vital signs and lab reports at 9.30 am

Progress notes in NICU

• Essentially the same scheme albeit some minor modifications

• F-IMNCI recommends the following

T – temperature

A – airway

B – breathing

C – circulation

F – fluids

M – medications

F – feeding

M – monitoring

C – communication

F – follow-up

An FTNV newborn with no significant ante-natal history has not cried,is deeply comatosed, limp with all extremities extended, had oneepisode of multifocal seizures. A provisional diagnosis of HIE stage IIIwas made. Ventilatory support was needed as he had irregularrespiratory pattern and was not able to maintain adequate SaO2 onsupplemental oxygen. His clinical condition deteriorated all of a

sudden while on mechanical ventilation.

CASE SCENARIO

Comatosed, no seizures , AF at level, fixed mid dilated pupil

Tone – flaccid

Neonatal reflexes – absent

Abdomen soft , no organomegaly

No icterus, purpura, petechie, bleeding from any site

On intravenous fluid (D10%) 50 ml tid

Injectable antibiotics, Inj. Ca. gluconate

Anticonvulsants, dopamine

NPO

Monitor vitals, SaO2 weight gain

Watch for seizure activity, abrupt changes in BP,HR, SaO2

Monitor urine output

Watch for bleeding, icterus

Complete blood count Sepsis screenBUN, Sr. creatinine, urinary ᵦ-2-microglobulinLFT, Blood sugarSr. lytescTNI,cTNT,CK-MBABGDWI,MRS,EEGPrognosis explained Review with lab reports at 10.00am or when needed

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