Top Tips for Writing Effective Progress Notes

Top Tips for Writing Effective Progress Notes Effective progress notes play a key role in supporting the treatment plan by providing a picture of the patient’s successes, difficulties, and needs.

Good progress notes tell the patient’s story and prioritize patient care and safety. Also referred to as SOAP (Subjective, Objective, Assessment, Plan) notes, progress notes are important reports that document various aspects of the patient’s treatment and highlight important issues or concerns relating to care. A professional medical transcription company can help physicians document these reports in the electronic health record (EHR).

Progress notes provide information for 

Medical decision-making

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Critical thinking and clinical reasoning

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Billing and coding – for correct assignment of codes

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Medico-legal documentation

To be effective, progress notes must be accurate, complete, factual, organized, timely, compliant with health laws and meet facility standards. It is important for progress notes to include treatments provided in chronological order, assessment of the patient’s response to the treatment, important events, emergencies and action taken, clinical impressions regarding diagnosis, treatment plan, medications used by the patient, collaboration with other professionals, referrals made, reasons for making referrals, safety issues, recommendations for revisions in the treatment plan, and more.

Here are some tips for writing effective progress notes 

Listen carefully to the patient’s story and document them, as it form the clinician’s assessment

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Refer to specific components in the treatment plan, to establish the link between the progress note entry and the patient’s treatment plan

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Summarize information about a series of treatment services into a single progress note

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Record all details of unusual events such as the reason for the event’s occurrence and how staff responded

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Ensure that assessment is documented correctly, even if the provider is unsure about something

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Make sure that the progress note should include the treatment plan, tests, and therapies

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Avoid abbreviations and strictly avoid cutting and pasting from previous notes without editing and updating the information

Random use of the EHR copy-paste function can lead to inconsistent progress notes and unnecessarily long progress notes. It is really important for the healthcare organizations to have clear policies and procedures in place to ensure proper EHR documentation and provide education and training for clinicians to promote good progress notes. Medical transcription outsourcing is a practical way to ensure EHR-integrated progress notes that are focused, concise, readable, organized, and useful.

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