Topics About 'Progress Notes'.

Hi there— We’ve been having an ongoing discussion at my hospital as to whether or not surgeons need to be CCed on to our daily surgical progress notes for billing purposes. Typically I have only been adding them if it is an initial surgical cons...

Hello . I'm trying to find a good cheat sheet for when I write antibiotic infection notes and progress notes on residents/patirnts. I plan on using the acronym SOAP for structure. I would like a little more guidance in verbage and make the best notes...

I want to know your thoughts regarding management creating addendums on progress notes written by another? Please share your opinions. Thank you

I am an international nurse and my medical English is not very good. I had a patient who vomited and I want to write about how much she vomited and what kind of things she vomit, but I don't know the exact English words to describe the vomiting thing...

Can somebody give an advise regarding documentation in progress notes. Can i write everything even if it is almost pages long!