How to Write a Medical Progress Report

The purpose of a medical progress report is to provide better patient care, as it gives members of a healthcare team the opportunity to note their observations as to a patient's condition, including any adverse effects of medication. In most cases, progress notes are recorded daily so that all members of the medical staff attending to a patient are informed about problems, diagnostic tests, medications and treatments. Progress notes are an important tool for communicating facts about a patient's condition, however, the information should be organized in such a way that others can easily follow the patient's progress.

Instructions

• 1

  Identify the patient by indicating his or her demographics at the top of the page. The patient's name, chart number, address, home telephone number, sex, Social Security number and date of birth are usually listed. Some reports include the patient's occupation, work telephone number and the name of the guarantor as well. The patient's height, weight and race may also be included, as this information frequently offers clues to a possible cause for the medical problem(s) being addressed.

• 2

  Include the date of the report in addition to the names and initials of any people making entries on the report. All entries should be initialed by the person making the notation.

• 3

  Summarize briefly the patient's primary complaint and description of symptoms, current medical conditions and past medical history, including relevant facts from the family medical history. Note any aspects of the patient's lifestyle, which present significant risk factors (e.g. smoking, alcohol/drug abuse).

• 4

  Describe any abnormalities noticed when performing a physical examination. Log the patient's vital signs and the details of even subtle changes observed in the patient.

• 5

  Make notes related to the patient's diet, as diet can sometimes affect a person's progress. For example, certain foods are known to interfere with medication, either increasing or decreasing a drug's effectiveness. Food can also cause allergic reactions and should be ruled out as the cause when a drug allergy is suspected.

• 6

  Keep a record of labs, diagnostic tests and any imaging studies. Be sure to indicate the date on which the tests were ordered. Record the results. Write a brief summary about any procedures performed, as well as the findings. The report should describe the patient's response to treatment, whether successful or ineffective. Make a note of impressions offered by other healthcare practitioners as the result of medical consults.

• 7

  List all medications the patient is currently taking. Include the name of the medication, strength, dosage and prescribed route of administration (e.g. oral, injected, topical, inhaled). Identify any medication that is being discontinued. Include the name of the drug and the type of reaction. Medication history should also include any nonprescription drugs or herbals the patient is taking.