Table of Contents

1. Components of a Progress Note
2. Subjective
   a. Common mistakes
3. Objective
   a. Common mistakes
4. Assessment
   a. What is your assessment?
5. Plan

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Components of a Progress Note 

As an internal medicine resident, you must develop the skill of documenting appropriately and effectively. A progress note is a legal document to communicate your patient care and involvement. You never know who will stumble upon your documentation, so you must write a good note. 

• Subjective
• Objective
  • Vitals
  • Physical exam
• Assessment
• Plan

Subjective

A subjective should only contain subjective data. This includes the patient’s own words and nursing communication. This can also include overnight events. Please see the example below. 

Example 1: “Patient states he is feeling better, and he is no longer experiencing chest pain. He denies further episodes of palpitations, dyspnea, nausea, or vomiting.” 

This is an example of a patient communicating in their own words.

Example 2: “Per nursing staff, the patient had an episode of emesis described as non-bloody and non-bilious. Zofran was administered x 1, and emesis episodes resolved.” 

This is an example of a nursing communication. 

Example 3: No acute events overnight. The patient denies any acute complaints. 

This is an example of concisely stating that there were no acute events. 

Common mistakes

• Writing your impression or assessment. 
• Writing vital signs. 
• Stating no events occurred when the patient was given multiple PRNs during the night.
• Copying and pasting previous notes and not changing pertinent information. 

Objective

If you use Epic or another EMR system, this area will likely be auto-populated. Your objective area should look something like the following: 

• Vitals
• Physical exam 
• Labs
• Imaging

Common mistakes

• Stating a person is well appearing when they are frail, malnourished, or in acute distress.
• Copying and pasting previous physical examinations. 
• Writing physical exams that you did not perform.
  
  Remember, any note you write is a legal document. If your notes are chosen to be reviewed in a court, for example, they may be deemed unreliable if it is noted that the documenter is not appropriately documenting. 

Assessment 

This is the hardest part to master. It will take time, but one needs to be organized so a reader can easily follow your thought process. An assessment is when you commit to a diagnosis. A diagnosis does not have to necessarily be right, but at least you have a direction you follow. You will also discuss relevant differential diagnoses. As an intern, you must go through this exercise to become a well-developed physician and not pigeonhole yourself to one diagnosis.

Example: Let’s say a 58-year-old man with uncontrolled hypertension and type 2 diabetes presents to the emergency department with a complaint of left-sided chest pain that radiates to the shoulder, is relieved at rest, and is associated with nausea and vomiting. In the ED, a work-up reveals elevated troponin and ST depressions in multiple leads. 

What is your assessment?

#Chest pain 

Or 

#Acute coronary syndrome, NSTEMI 

Some common mistake expected as an intern is not being specific enough regarding a diagnosis. It is not wrong to state chest pain, but it also does not provide a lot of information or a working diagnosis. There are many reasons for chest pain and many ways it can be treated. Therefore, specificity is essential. 

Taking it a step further, we need to discuss our thought process and think of 2 to 3 differentials that merit writing out. 

Example: 

#Acute coronary syndrome, NSTEMI
Mr. Yoon is a 58-yo male with multiple risk factors for acute coronary artery disease, which include uncontrolled hypertension, type 2 diabetes, obesity, and tobacco abuse. He does not follow with a primary regularly. He presents with typical chest pain relieved with rest in the setting of troponinemia and ECG changes most consistent with an NSTEMI and will need further ischemic workup. If work-up is negative, other differentials should be considered, including GERD, costochondritis, or anxiety, though all unlikely given his significant lab and ECG findings.  

This addresses why the author believes that the patient has an NSTEMI. The author then includes other differentials but makes it apparent that these differentials are very low on the list. This case is straightforward, but some patients will not present in such a forward manner. Thus, it is important to commit to a diagnosis, explain your thought process, and give other potential differentials.  

Finally, being able to integrate problems as one instead of separating each one out demonstrates the mastery of medicine. For example, a young doctor may separate out chest pain, nausea/vomiting, and elevated troponins. However, we can see that they are all related, given his likely diagnosis. Whenever you have a patient with multiple problems, challenge yourself to see how each problem may be related. 

Plan

Once you have your assessment, you must come up with your plan. It is important to be specific and direct. Taking our chest pain example, we should see the following: 

#Acute coronary syndrome, NSTEMI – GRACE Score 77 points, TIMI Score 4 points
Mr. Yoon is a 58-yo male with multiple risk factors for acute coronary artery disease, which include uncontrolled hypertension, type 2 diabetes, obesity, and tobacco abuse. He does not follow with a primary regularly. He presents with typical chest pain relieved with rest in the setting of troponinemia and ECG changes most consistent with an NSTEMI and will need further ischemic workup. If work-up is negative, other differentials should be considered, including GERD, costochondritis, or anxiety, though all unlikely given his significant lab and ECG findings.  

• Load with ASA 325 mg and c/w ASA 81 mg daily
• Load with clopidogrel 600 mg and c/w clopidogrel 75 mg daily
• Ordered atorvastatin 80 mg daily 
• Ordered troponin q3h until peak with ECGs
• Ordered 2D echocardiogram to assess for wall motion abnormality
• Will consult cardiology for invasive vs non-invasive ischemic workup

If the writer has done an excellent job explaining their assessment, it is likely the plan will not need further explanation. However, if it is unclear why a lab or other imaging is ordered, a writer should provide further explanation. 

Please keep in mind that every attending has a style that they choose to write in. However, I found this method to be the most organized and effective way to relay my thought process. Thank you so much for reading my post, and do not hesitate to reach out for more advice.

xoxo, Dr. M.