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Education and learning
Your note, your way: how to write an inpatient progress note accurately and efficiently as an intern
  1. Miao Wei1,
  2. Efrain Salgado2,
  3. Christine E Girard3,
  4. Jonathan D Santoro4,
  5. Natasha Lepore5
  1. 1Internal Medicine, Cleveland Clinic Florida, Weston, Florida, USA
  2. 2Department of Neurology, Cleveland Clinic Florida, Weston, Florida, USA
  3. 3Department of Internal Medicine, Cleveland Clinic Florida, Weston, Florida, USA
  4. 4Department of Neurology, University of Southern California, Los Angeles, California, USA
  5. 5Department of Radiology, University of Southern California, Los Angeles, California, USA
  1. Correspondence to Dr Efrain Salgado, Department of Neurology, Cleveland Clinic Florida, Weston, FL 33331, USA; salgade{at}ccf.org

Abstract

A physician’s progress note is an essential piece of documentation regarding key events and the daily status of patients during their hospital stay. It serves not only as a communication tool between care team members, but also chronicles clinical status and pertinent updates to their medical care. Despite the importance of these documents, little literature exists on how to help residents to improve the quality of their daily progress notes. A narrative literature review of English language literature was performed and summated to provide recommendations on how to write an inpatient progress note more accurately and efficiently. In addition, the authors will also introduce a method to build a personal template with the goal of extracting relevant data automatically to reduce clicks for an inpatient progress note in the electronic medical record system.

  • INTERNAL MEDICINE
  • MEDICAL EDUCATION & TRAINING

http://dx.doi.org/10.1136/postgradmedj-2022-141834

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    Footnotes

    • Contributors MW performed article collection, literature review, drafted and revised the manuscript. CEG assisted with the literature review and revised the manuscript. JDS, NL and ES assisted with study design, contributed to revising it critically and all authors approved the final manuscript as submitted.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.