What are progress notes?

Progress notes are a vital part of medical documentation that provide ongoing updates about a patient's condition, treatment, and response to care throughout the duration of their hospitalization. These notes are typically authored by physicians and include detailed observations, interventions, and modifications to the treatment plan based on the patient's evolving status. Progress notes serve to ensure continuity of care, allowing any healthcare provider who reviews the record to understand what has transpired, the medical decision-making processes involved, and any updates required for future care.

While observations during follow-up visits are important for outpatient care and may be documented separately, progress notes specifically refer to those written during hospitalization for acute care settings. Similarly, patient history summaries offer an overview of past medical history but do not capture the ongoing changes in a patient’s condition or treatment. Nursing assessments provide valuable information about patient health but focus primarily on initial evaluations and individual assessments rather than the ongoing tracking specific to physicians’ notes in the context of hospitalization.