Progress Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

<b>Progress Note</b>

Patient Identification: [Patient name, age, gender, with a history of..., admitted for...]

<b>Interval history:</b>
(Update of the patient since the last encounter in paragraph form. Use full sentences and formal clinical language. State facts plainly. If mentioned, review of systems should be the last paragraph.)

<b>Physical Examination:</b>
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Physical exam findings and/or mental status exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant)

<b>Investigations:</b>
(hyphenated list)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

<b>Assessment & Plan:</b>
(Do not fabricate the assessment and plan unless mentioned in the source material. Use medical terminology if appropriate)

#) [List the assessment as a numbered item]
- [Hyphenated list with corresponding items underneath]