Medical Reports

Progress Report

Samina Najeeb
Why are medical progress reports
written?
 The purpose of a medical progress report is to provide better patient
care, as it gives members of a healthcare team the opportunity to
note their observations as to a patient's condition, including any
adverse effects of medication.
 In most cases, progress notes are recorded daily so that all members
of the medical staff attending to a patient are informed about
problems, diagnostic tests, medications and treatments. Progress
notes are an important tool for communicating facts about a patient's
condition, however, the information should be organized in such a
way that others can easily follow the patient's progress.
How to document them?
 Identify the patient by indicating his or her demographics at the top of the page.
The patient's name, chart number, address, home telephone number, sex, Social
Security number and date of birth are usually listed. Some reports include the
patient's occupation, work telephone number and the name of the guarantor as
well. The patient's height, weight and race may also be included, as this
information frequently offers clues to a possible cause for the medical
problem(s) being addressed.

 Include the date of the report in addition to the names and initials of any people
making entries on the report.
More instructions
 Summarize briefly the patient's primary complaint
and description of symptoms, current medical
conditions and past medical history, including
relevant facts from the family medical history.
Note any aspects of the patient's lifestyle, which
present significant risk factors (e.g. smoking,
alcohol/drug abuse).
Instructions contd…..
 Describe any abnormalities noticed when
performing a physical examination. Log the
patient's vital signs and the details of even subtle
changes observed in the patient.
More things to be noted….
 Make notes related to the patient's diet, as diet can
sometimes affect a person's progress. For example,
certain foods are known to interfere with
medication, either increasing or decreasing a
drug's effectiveness. Food can also cause allergic
reactions and should be ruled out as the cause
when a drug allergy is suspected.
Also note:
 Keep a record of labs, diagnostic tests and any imaging
studies. Be sure to indicate the date on which the tests
were ordered. Record the results. Write a brief summary
about any procedures performed, as well as the
findings. The report should describe the patient's
response to treatment, whether successful or ineffective.
Make a note of impressions offered by other healthcare
practitioners as the result of medical consults.
 List all medications the patient is currently taking.
Include the name of the medication, strength, dosage
and prescribed route of administration (e.g. oral,
injected, topical, inhaled). Identify any medication that
is being discontinued. Include the name of the drug and
the type of reaction. Medication history should also
include any nonprescription drugs or herbals the patient
is taking.
Tips & Warnings

 A final medical progress report should document

the patient's diagnosis, medical condition on
discharge and any specific instructions related to
medication, diet and follow-up care. Many
hospitals now have a policy where both a doctor
and nurse are required to review a patient's
medication in order to reduce the risk of
medication errors.
Progress Reports Documentation
 must include a short narrative progress report with objective
information presented in a clear, concise manner.
 This informs the reviewer of progress in meeting the plan of
treatment, along with any changes in the goals or the
treatment plan.
 Progress reports or a treatment summary may include: initial
functional communication level of the patient present
functional level of the patient and progress (or lack of
progress) specific to the reporting period patient's expected
rehabilitation potential changes in the plan of treatment.
You may use terms like:
Medical history: brief description of functional status, and
prior treatment details.
disorder:
diagnosis established by the help of reports
Date of onset: date of onset of related disorder diagnosis.
Physician referral: if required.
Initial assessment and date:
Plan of treatment or a treatment program and date
established.
Progress notes or reports: updated patient status reports.
Activity
 Design a Medical report progress form

 And record the progress of your patient in the

designed form.
 Thank you
