What to expect in patient's "Progress Notes"?

  1. 0 Med/surg new grad here. My biggest challenge right now is communicating with different health care members because I don't get informed with every information. I've seen nurses look in the patient's "progress notes" in the chart for answers... so I'm wondering, who typically writes in "Progress Notes" and what useful information can I expect from that section of the patient's chart?

    Thank you!
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  3. Visit  nurs1ng} profile page

    About nurs1ng

    Joined May '12; Posts: 91; Likes: 15.

    10 Comments so far...

  4. Visit  Altra} profile page
    0
    Highly suggest you read progress notes -- they'll contain brief H&Ps, and A/P -- assessment/plan.

    If you are caring for the patient, their entire chart (paper or electronic) is available to you -- be sure to utilize it!
  5. Visit  turnforthenurseRN} profile page
    2
    There have been times where I have read a physician's progress notes and something is mentioned in the plan but the order was never written. It is definitely a good idea to read the progress notes.
    KelRN215 and dudette10 like this.
  6. Visit  Sun0408} profile page
    0
    All involved with the pt write in the progress notes except nurses, we have a separate location for notes. If the pt has consults, social worker, discharge planning, hospice etc their plan/recommendations will usually be written in the progress notes.

    As mentioned above, please read them. It will give you an idea of what the MD's are thinking, where they are heading and prognosis. Some are really good at writing while others give little to no information.
  7. Visit  GrnTea} profile page
    0
    Progress notes should be integrated with all disciplines participating on the same pages, so the reader can follow the patient's, ummm, progress chronologically and all disciplines can follow the care given and rationales (evals, exam findings, response to treatments) by all other disciplines. If your facility still follows the archaic "nurses notes in the back, doctors notes in the front" formula, advocate for integration.

    Think of your notes as communication devices in that way-- help everyone out.
  8. Visit  amoLucia} profile page
    1
    Dear GrnTea - Normally I agree with you, but on this issue I differ. I've worked LTC places that DID integrate all the notes into an INTERDISCIPLINARY Note at one time. But they all reverted. Why??? All the disciplines worried about all the big gaps left on the page by the MDs who continued to write in their big scrawly loopy handwriting. And the MDs liked their own section - they didn't care to sift thru the notes to find their own LAST entry to continue.

    And my personal pet peeve - there was NO courtesy by most to put new pages as nec into the chart. So rude!

    Of course, I'm talking about paper & pen type charting. I'm sure electronic charting has probably remedied these problems.
    BrandonLPN likes this.
  9. Visit  eatmysoxRN} profile page
    0
    I usually glance at the progress note at shift start because it helps me to plan my care for the shift. If it is written to increase ambulation, I'll try to get the patient up to walk a bit. It's also easier to answer questions regarding what's going on when I read the progress note.

    ~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~
  10. Visit  ~PedsRN~} profile page
    0
    Basically they will give you an idea of what the doctors are planning for this patients care. Ours will actually have "impression" and "plan for treatment" charted in the progress notes. It's always a good idea to see if the orders you have in front of you match up with the plans for treatment.
  11. Visit  BrandonLPN} profile page
    1
    Quote from amoLucia
    Dear GrnTea - Normally I agree with you, but on this issue I differ. I've worked LTC places that DID integrate all the notes into an INTERDISCIPLINARY Note at one time. But they all reverted. Why??? All the disciplines worried about all the big gaps left on the page by the MDs who continued to write in their big scrawly loopy handwriting. And the MDs liked their own section - they didn't care to sift thru the notes to find their own LAST entry to continue.And my personal pet peeve - there was NO courtesy by most to put new pages as nec into the chart. So rude!Of course, I'm talking about paper & pen type charting. I'm sure electronic charting has probably remedied these problems.
    Our nurses notes section in the chart is titled "interdisciplinary notes", too. But it might as well just be called "nurses notes" cause we're the only ones who chart there. Physicians have their own section, as do social work. Besides, all the physicians notes are dictated. It takes a week or so for the printed out copies to make it to our facility. So trying to integrate the dictated physicians notes with the pen and paper nurses notes in some sort chronological order would be a logistical nightmare.
    amoLucia likes this.
  12. Visit  KelRN215} profile page
    0
    Quote from Sun0408
    All involved with the pt write in the progress notes except nurses, we have a separate location for notes. If the pt has consults, social worker, discharge planning, hospice etc their plan/recommendations will usually be written in the progress notes.

    As mentioned above, please read them. It will give you an idea of what the MD's are thinking, where they are heading and prognosis. Some are really good at writing while others give little to no information.
    I always considered my nursing notes progress notes when I worked in the hospital, especially since we titled our notes "Nursing Progress Note".

    We had Inpatient Notes for MDs, RNs, Nutrition, PT, OT, Speech, Social Work, Case Management, Chaplaincy and I'm sure some other discipline that I'm forgetting. I would consider all of these progress notes. Every discipline has their own goals and their own criteria to measure progress in the patient. MDs who were consultants wrote Consult Notes. I always read the notes though I don't think most others did. I know that no one ever read our nursing notes except for other nurses.
  13. Visit  liveyourlife747} profile page
    0
    I agree with all the previous posters. Also some MDs break down "problems" that the pt came in with or developed and they list assessment findings related to that as well as their plan. Since most MDs won't call and let you know about what they are wanting to do with the pt, you should be reading them to feta general idea of what's going on. Eventually you will start to see trends with different diagnoses and how they are treated. With that, you can be able to anticipate new orders related to that diagnosis and be able to answer Pts questions about the typical plan of care for that diagnosis.


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