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Progress Note Questions



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Feb 22, 2009 05:53 PM

Progress Note Questions


I am working on progress notes to turn in for maternity clinical and am having trouble getting started. Should you start with a brief pt history and then go into v/s and pt care or just document pt care and leave it at that?

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from Daytonite
Old Feb 23, 2009, 12:31 PM

Why not follow something like a SOAP note when you chart:
  • S - subjective data
  • O - objective data
  • A - your assessment based upon the data
  • P - your plan of action (what you did about anything that was abnormal)
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