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Appendix 4 - Daily Progress Note Template

Published online by Cambridge University Press:  05 August 2011

Richard A. Loftus
Affiliation:
San Francisco General Hospital
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Summary

Included is a template for a daily progress note. As an intern, I've noticed that while using the blue card for collecting pre-round data was fine when I carried 1–3 patients, it's less time efficient for more patients, and I've resorted to pre-rounding directly onto a full-size note. Once I finish the note, I add the daily labs to my yellow card, photocopy the note (many wards have faxes that double as copiers), pop the original in the chart, and keep the copy folded vertically in my pocket for reference. I still find the tan and yellow cards handy.

The upper right corner of the note allows you to stamp the page with the patient's ID card.

The bottom of the front and back has your name, ID code, and pager number. You can customize this template with your appropriate info, then photocopy a bunch of two-sided copies to keep on hand for pre-rounding. It saves time.

Important: The following template may need to be printed onto hospital progress notes stationery – it may violate medical records rules otherwise, and your notes will be culled out of the chart. Once you've printed this onto a progress notes form (you may need to play with the formatting a bit), use that as an original and make two-sided copies for your notes.

Information

Type
Chapter
Information
The Nerd's Guide to Pre-Rounding
A Medical Student's Manual to the Wards
, pp. 117 - 120
Publisher: Cambridge University Press
Print publication year: 2006

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