Inpatient Progress Notes and Critical Care Notes
By Walter A. Reiling III, MD, Chief Medical Informatics Officer, Premier Health
One of the most frequent complaints from Premier Health physicians is that progress notes are frequently not helpful. Some have very little documentation of the assessment and plan, or have that information buried in a huge volume of linked data that is more easily reviewed elsewhere in the medical record.
The physicians on the Premier Physician Documentation Oversight Committee created standards on accepted progress note standards. These standards are part of a larger group of documentation guidelines endorsed by all four hospital Medical Executive Committees. The full document is available online for review on the physician portal.
Below, please find the standards relevant to progress notes. Following these will facilitate greater efficiency in patient care and documentation.
Frequency – In general, progress notes should be placed on the patient record each day, or in accordance with the hospital rules and regulations contained with the facility’s bylaws.
Timing – The progress note should be placed on the chart as close as possible to the time the patient is evaluated.
Necessary Components – In general, the note should include a summary of the patient’s status, including subjective and objective data. A meaningful, clear, and concise assessment and plan is also required. A referral to review the plan in the “orders” section of the chart is not acceptable, as it can be difficult to understand the plan in this manner and does not result in the best patient care.
What not to include – The daily progress notes should not include large volumes of linked data that is readily available in other portions of the record. In general, if the data is already in the EMR and is not directly pertinent to the medical decision making, it should not be duplicated in the note. It is acceptable to include statements such as “lab data reviewed in results review,” in order to document that you have looked at the information.
Following these guidelines will make the progress notes more useful and easier to read.
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