Assignment: Progress Note

Assignment: Progress Note

Assignment: Progress Note

Week 2 assignment SOAP Note and CORE Entries Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template . The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE. Submission Details: By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided. Name your SOAP note document SU_NSG6340_W2_SOAPLastName_FirstInitial.doc. Include the reference number from CORE in your document. Submit your document to the Submissions Area by the due date assigned.

Progress Notes are the part of a  where  professionals record details to document a ‘s clinical status or achievements during the course of a  or over the course of . Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the , where the note is organized into Subjective, Objective, Assessment, and Plan sections. Another example is the DART system, organized into Description, Assessment, Response, and Treatment. Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both  and  to document patient care on a regular interval during a patient’s hospitalization.

Progress notes serve as a record of events during a patient’s care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other members of the medical care team, and allow retrospective review of case details for a variety of interested parties. They are the repository of medical facts and clinical thinking, and are intended to be a concise vehicle of communication about a patient’s condition to those who access the health record. The majority of the medical record consists of progress notes documenting the care delivered and the clinical events relevant to  and treatment for a patient. They should be readable, easily understood, complete, accurate, and concise. They must also be flexible enough to logically convey to others what happened during an encounter, e.g., the chain of events during the visit, as well as guaranteeing full accountability for documented material, e.g., who recorded the information and when it was recorded. 

Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient’s chart and used for medical, legal, and  purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be required anywhere from several times an hour to several times a day.