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Specialist In Internal Medicine
10-15 minutes

Inpatient Physician Progress Note

The s10.ai Hospitalist Progress Note template is expertly crafted for internal medicine specialists to efficiently document the clinical trajectory and daily updates of hospitalized patients. This comprehensive template features sections for summarizing the patient's condition, significant events, and interventions since admission, along with detailed physical examination findings, assessment, and plan for each medical issue. It also includes specifics on fluids, diet, and prophylaxis, making it an indispensable tool for tracking patient progress and planning discharge. Ideal for hospitalists and inpatient care providers, this template streamlines documentation and enhances patient care coordination, encouraging clinicians to adopt and implement it for improved healthcare delivery.

1,860 uses
4.2/5.0
J
Jonathan Reynolds
Template Structure

Organized sections for comprehensive clinical documentation

Clinical Course:
Patient is a [insert age] with a history of [insert past medical history]. Patient presented to [insert hospital name] (if transferred, mention the transfer and the previous hospital's name. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) and was admitted with the diagnosis of [insert admission diagnosis] with the chief complaint of [insert admission chief complaint]. Summarize the patient's clinical course since admission, including any significant events, changes in condition, or interventions. (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank.)
Today's Updates [Insert date of current consultation in US format]:
[Describe the patient's condition and any significant events or interventions in the last 24 hours in a narrative format.] (Only include if explicitly mentioned in the transcript, otherwise state "No significant events in the last 24 hours.")
[Describe any new changes related to the significant events in a narrative format.] (Only include if explicitly mentioned in the transcript, otherwise leave blank.)
[Relevant imaging results and their interpretation that were obtained in the last 24 hours in a narrative format.] (Only include if available in the transcript or contextual notes, otherwise omit.)
[Relevant test results and their interpretation for the date of the note in a narrative format.] (Only include if available, otherwise omit.)
[Provide a summary of bedside questions responded to and education provided as mentioned in the transcript.] (Only include if explicitly mentioned in the transcript, otherwise leave blank.)
Review of Systems (ROS):
[List any relevant positive or negative findings from the review of systems.] (Only include if explicitly mentioned in the transcript, otherwise leave blank.)
Physical Exam:
[Describe the findings from the physical examination, including vital signs, general appearance, and specific system examinations.] (Only include if explicitly mentioned in the transcript, otherwise use the default below:)
General: Alert and oriented, well-nourished, no acute distress.
Lungs: Clear to auscultation, non-labored respiration.
Heart: Normal rate, regular rhythm, no murmur. No LE edema.
Abdomen: Soft, non-tender, non-distended, normal bowel sounds.
Musculoskeletal: No finger cyanosis.
Neurologic: No facial weakness.
Psychiatric: Cooperative.
Assessment and Plan:
[Patient's age, past medical history, and brief 1-3 sentence clinical course summary.]
1. [Medical issue 1 (condition name)]
- Assessment: [Current assessment of the condition.]
- Plan: [Proposed plan for management or follow-up.]
- Counseling: [Description of the condition, natural history, or similar.] (Include only if discussed, otherwise omit.)
2. [Medical issue 2 (condition name)]
- Assessment: [Current assessment of the condition.]
- Plan: [Proposed plan for management or follow-up.]
- Counseling: [Description of the condition, natural history, or similar.] (Include only if discussed, otherwise omit.)
3. [Medical issue 3, 4, 5, etc. (condition name)]
- Assessment: [Current assessment of the condition.]
- Plan: [Proposed plan for management or follow-up.]
- Counseling: [Description of the condition, natural history, or similar.] (Include only if discussed, otherwise omit.)
Fluids, Electrolytes, Diet: [Insert current IV fluids (if explicitly mentioned), electrolytes requiring replacement (if explicitly mentioned), and current diet (if explicitly mentioned). Otherwise, omit.]
DVT prophylaxis: [List the name of the ordered anticoagulant (e.g., Enoxaparin sodium, Heparin, Coumadin, Apixaban, Rivaroxaban) if explicitly mentioned, otherwise leave blank.]
Central line: [Insert "Present" (with indication for use) or "Not applicable" based on the transcript, otherwise leave blank.]
Foley catheter: [Insert "Present" (with indication for use) or "Not applicable" based on the transcript, otherwise leave blank.]
Code Status: [Insert Code Status (e.g., "Full Code," "DNR," "DNR/DNI," "DNI," "Comfort Care") if explicitly mentioned, otherwise leave blank.]
Disposition: [Insert the expected discharge date, pertinent medical issues affecting hospitalization, and discharge plans (rehabilitation, social services efforts) if explicitly mentioned, otherwise leave blank.]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note.)
Sample Clinical Note

Example of completed documentation using this template

Clinical Course:  
Patient is a 68-year-old male with a history of hypertension, type 2 diabetes, and chronic kidney disease. He was admitted to City Hospital with a diagnosis of pneumonia, presenting with shortness of breath and fever. Since admission, he has been started on IV antibiotics and oxygen therapy. His condition has gradually improved, with reduced fever and better oxygen saturation levels.
Today's Updates 10/15/2023:  
The patient's condition has stabilized with no significant events in the past 24 hours. He continues to respond well to the antibiotic treatment.
Relevant imaging results: Chest X-ray indicates resolving infiltrates in the right lower lobe.
Relevant test results: Blood cultures remain negative, and inflammatory markers have decreased.
Review of Systems (ROS):  
No new positive or negative findings reported.
Physical Exam:  
General: Alert and oriented, well-nourished, no acute distress.  
Lungs: Clear to auscultation, non-labored respiration.  
Heart: Normal rate, regular rhythm, no murmur. No LE edema.  
Abdomen: Soft, non-tender, non-distended, normal bowel sounds.  
Musculoskeletal: No finger cyanosis.  
Neurologic: No facial weakness.  
Psychiatric: Cooperative.
Assessment and Plan:  
68-year-old male with hypertension, type 2 diabetes, and chronic kidney disease, admitted for pneumonia.
1. Pneumonia  
- Assessment: Improving with current treatment.  
- Plan: Continue IV antibiotics and monitor respiratory status.  
- Counseling: Discussed the importance of completing the antibiotic course and monitoring for any new symptoms.
2. Hypertension  
- Assessment: Blood pressure well-controlled on current medications.  
- Plan: Continue current antihypertensive regimen.
3. Type 2 Diabetes  
- Assessment: Blood glucose levels stable.  
- Plan: Continue current diabetic management and monitor blood glucose levels.
Fluids, Electrolytes, Diet: Patient on a regular diet with adequate hydration.  
DVT prophylaxis: Enoxaparin sodium ordered.  
Central line: Not applicable.  
Foley catheter: Not applicable.  
Code Status: Full Code.  
Disposition: Expected discharge in 2 days with follow-up in the outpatient clinic for continued management of chronic conditions.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical course template is designed to streamline patient documentation, ensuring healthcare professionals can efficiently capture and communicate critical patient information. By incorporating high-search healthcare keywords, this template enhances clinical accuracy and facilitates seamless integration into electronic health records. Clinicians can easily document patient history, admission details, and summarize the clinical course, including significant events and interventions. The template also provides structured sections for daily updates, review of systems, physical exams, and detailed assessments and plans for each medical issue. With dedicated fields for fluids, electrolytes, diet, and prophylaxis, this template supports thorough patient management. Adopt this template to improve documentation efficiency, enhance patient care, and ensure compliance with clinical standards.
Frequently Asked Questions

Common questions about this template and its usage

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