First person active tense is more effective than the passive voice
Simple declarative sentences are best. Short sentences are good.
Make observations about the patient. e.g.
• Mr. Jones is dyspneic at rest
• Mr. Jones says he is hungry and feels better
• Tachycardia and fever are present this AM
• The patient is incontinent and thinks it is 1957 this AM
• Mr. Jones says he feels better and I think he looks better
• Mr. Jones is angry and upset this morning because . . .
• The bedside commode is filled with a melenic stool
Examples of useful ways to include lab data in the progress notes include the
following:
• Thrombocytopenia noted
• Creatinine is rising -- probably because of gentamicin therapy
• Hypokalemia is improving with K replacement
• Leukocytosis is presumably due to his pneumonia
• Hyponatremia and hyperkalemia are confusing; the latter may be
spurious, will repeat; if it is real, will check a cortisol
• AM lab results reviewed: no surprises found
• Lab results fit with our working diagnoses: anemia is probably due to
his renal failure
• Anemia noted---if it worsens we will transfuse
• Hyponatremia is in part spurious---(note: Glucose is 680)
• Routine labs all normal or OK
It is often good and useful to explain your thinking in the chart e.g.
• We think his confusion is related to more than one thing: (underlying
dementia and electrolyte abnormalities)
• Persistent fever is a worry to us; if it continues tomorrow, we will look
for a cause other than his pneumonia
• We do not plan to reinvestigate his anemia—this has been fully
evaluated in the past and is due to his chronic disease
• We are concerned about his ileus and will get a surgical consultation
• The ileus could be due to his electrolyte disturbance, will correct his
lytes and if it doesn’t improve, we will seek an opinion from Dr.
Wilson
It is useful to communicate with consultants using the progress notes. e.g.
• Question for Dr. Wilson: When do you plan to pull his NG tube?
• We would like the ID consult team to comment upon their
recommendation to change to imipenem: Is it better than the current
Rx of flagyl and cipro? If not, why change therapy?
• When the ID team makes rounds please page me at 970-4556: we
need to discuss the duration of antibiotic Rx
• We would like to arrange a management conference with GI and
surgery tomorrow—GI and surgery -- please indicate when you can
meet with us.
• We have asked GI to see the patient and comment upon these
questions:
o Is endoscopy indicated?
o Do they agree that jaundice is out of proportion to his LFT
abnormalities?
When dealing with a difficult patient or family, write down what was said e.g.
• Conference was held with the patient’s family this AM; we told them
the following:
o The pneumothorax that followed attempted placement of a
central line will require a chest tube for 3-7 days
o That we are aware of their complaints about his nursing care
• We told the patient that his kidney problems are not getting better.
WRITE LEGIBLY
It is not necessary to put the vital signs in each progress notes; although this can be
useful if they are abnormal (in which case, comments about their significance are
often helpful and/or appropriate) e.g.
o VS normal
o Resting pulse 125—believe the reason is hypoxia and CHF
o Pulse 120—still in atrial fib
Remember to read the nurses notes. This may keep you out of court.
If you don’t know what is wrong it is sometimes useful to state what isn’t wrong: eg.
We are fairly sure that the fever is not due to pneumonia, a UTI, or meningitis.