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progress notes (for inpatients)
#clerk
All progress notes should begin with a line summarizing the patient.
The remainder of the note follows the format “SOAP”:

Subjective
• How is the patient feeling, any concerns
• Pain control, nausea/vomiting
• Ambulating?
• Tolerating diet?
Objective
• Vital signs
• Drain outputs
• Urine output if relevant
• Findings on physical examination
Assessment
• How is the patient doing overall, what are the issues
Plan
• Summarize plan for each issue

Example
55F POD #3 bilateral immediate breast reconstruction with DIEP flaps
S: Patients feels well, pain controlled. Eating well. Ambulating.
O: AVSS. JP output: #1 50cc, #2 60cc – both serosanguinous. Flaps: good colour, cap refill, turgor. Both warm. Small blue discoloration lateral aspect right breast, 2x1 cm. Abdomen soft. Incisions clean, dry and intact.
A/P: Doing well. Continue to monitor flaps as per protocol. Reassess lateral aspect right breast this afternoon.
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Summary

statusnot read reprioritisations
last reprioritisation on suggested re-reading day
started reading on finished reading on

Details



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