When you hear the words inpatient and progress notes, you may either be a nurse or a healthcare professional, or even anyone who has worked with patients or in the hospital before. Because this kind of note is often only seen and written by those working in hospitals. This is a requirement for them to be able to get an idea of what the patient is feeling on a daily basis. Quite a challenge for those who are not able to know how or why it is used. Quite a useful note especially when you are going to be doing your rounds and learning more about the patient in the process. This is why there are some who may use the inpatient notes to complain because the information is incorrect. To avoid that from happening to you or to anyone in the future, let us learn or relearn what an inpatient progress note is and how you write it.
Inpatient notes are more commonly seen and used as a way to see any changes in the patient. We may not always hear about this since this kind of progress note is mainly used in hospitals. Nurses, psychiatrists, healthcare workers are no strangers when it comes to progress notes or even therapy notes. Apart from taking down notes for their assessments and evaluations, they are also tasked to write inpatient progress notes. These kinds of notes are a complete set of information about the patient, their daily progress of their health, their illness and their overall health status. This is also why many nurses and health care professionals are trained to understand that it is always important to be clear with your notes.
A lot of people think that writing an inpatient progress note would be difficult, complicated and stressful. There is always a better way of viewing how you are going to write it. As long as you know what you are going to be writing and what you are going to be adding as information. Just like any progress note or progress report, attention to detail is important. With that being said, here are your steps to writing an inpatient progress note.
Drafting can be optional if you have already learned how to write an inpatient progress note. But for those who find it difficult or it is their first time, writing down a draft should be your first step. Drafting helps by giving you the opportunity to just keep on writing what you have observed. The information you have collected while doing your rounds. Write them down. Don’t be afraid to make a mistake here, as this is still a draft and not the final output.
Details may vary but they are still details. Details about your patient, their progress, their status, their health day by day. These are important to notice. Pay very close attention to details. Details are important when you are writing your progress note. Your progress note should be filled with the correct details and not just something random to fill the form or your notes down.
This is something a lot of people may assume that it is okay. No, it is not. Avoid writing your own personal opinion about the welfare and status of the patient. The inpatient progress note must not include your personal opinion. It must only be written in a professional and well observed matter. Personal opinions are not guaranteed to be professional opinions.
The whole point of the inpatient progress report is to write down the day to day progress of the patient. Whether you are working as a nurse, a healthcare professional or a therapist, you would know that writing down their day to day progress is part of the note. To understand and see if there are any improvements that have been made and done.
When you have written out all what is necessary you must finalize your entire inpatient progress note. Avoid making any erasures about the progress note. Avoid any unnecessary information and above all else, avoid any issues that may not be a part of your notes.
An inpatient progress note acts like a SOAP note. It includes the day to day details and progress of a patient. It also includes details of the welfare and health of a patient. Inpatient progress notes are often used by medical practitioners and therapists to assess and evaluate the status of their patient.
Very important for nurses, doctors, therapists and anyone working in the medical and health fields to write their inpatient progress note. In order for them to know of the progress and to update their notes through careful observations.
Avoid writing a personal opinion about the patient. Never make any personal assumptions as the inpatient progress note does not require you to do so.
There are things to remember when you write your inpatient progress note. One is not to write something that you can assume is correct. If you think this is based on your personal opinion, do not add it. Two, updating your inpatient progress report is necessary. Three and definitely the last, always check your notes before handing them over.