What is a progress note?
A progress note documents a single patient encounter after the initial evaluation. It records what the patient said, what the clinician found, what the clinician concluded, and what comes next. It is the most-written document in clinical practice, and the one most often audited by payers.
Progress notes are written by physicians, NPs, PAs, nurses, therapists, social workers, physical therapists, occupational therapists, and dietitians. They follow different formats by setting and specialty: SOAP for most medical visits, narrative for some outpatient follow-ups, problem-based for inpatient daily notes, and DAP or BIRP for behavioral health.
A good progress note answers four questions in under one page: What is going on? What did I find? What does it mean? What are we doing about it? Anything that does not answer one of those questions probably does not belong.
What to include in a progress note
Required elements
- Patient identifier (name, DOB or MRN)
- Date and time of visit
- Type of visit (office, telehealth, inpatient day, etc.)
- Subjective findings: chief complaint, HPI, interval changes
- Objective findings: vitals, exam, mental status, labs, imaging
- Assessment: diagnosis or working diagnosis with reasoning
- Plan: medications, orders, education, follow-up timing
- Clinician signature, credentials, and date
Setting-specific elements
- Outpatient follow-up: medication adherence, response to last plan, vitals trend
- Daily inpatient: overnight events, problem list with plan per problem, anticipated discharge date
- Post-op day: postoperative day number, pain control, ambulation, drains, anticipated discharge
- Behavioral health session: mood, affect, risk assessment, progress toward plan goals, homework
SOAP-style outpatient progress note
The standard SOAP layout for an office or telehealth follow-up visit. Replace any field you do not need.
[PRACTICE NAME] OUTPATIENT FOLLOW-UP NOTE Patient: ______________________ DOB: ____/____/______ MRN: __________ Date of visit: ____/____/______ Visit type: [ ] Office [ ] Telehealth Clinician: ______________________ CC: __________________________ S - SUBJECTIVE HPI: _______________________________________________________________ ___________________________________________________________________ ROS: ______________________________________________________________ Medications reviewed and reconciled: [ ] Yes Adherence: [ ] Good [ ] Partial [ ] Poor O - OBJECTIVE Vitals: BP ______ HR ____ RR ____ Temp ____ SpO2 ____ Weight ____ Exam: _____________________________________________________________ ___________________________________________________________________ Labs/imaging: _____________________________________________________ A - ASSESSMENT 1. _______________________________________________ ICD-10: ________ 2. _______________________________________________ ICD-10: ________ Reasoning: ________________________________________________________ P - PLAN Medications: ______________________________________________________ Orders: ___________________________________________________________ Patient education: ________________________________________________ Follow-up: ____ weeks Modality: [ ] Office [ ] Telehealth Signed: __________________________ Date: ____/____/______
Daily inpatient progress note
Problem-based daily note for hospitalists, intensivists, and consulting services. The problem list and plan-by-problem structure are what most attendings expect.
[HOSPITAL] DAILY INPATIENT PROGRESS NOTE Patient: ______________________ MRN: __________ Room: ______ Hospital day: ______ Adm dx: __________________________________ Today's date: ____/____/______ Author: __________________ OVERNIGHT EVENTS ___________________________________________________________________ SUBJECTIVE Patient reports: __________________________________________________ OBJECTIVE Vitals (24h range): _______________________________________________ I/O: ____ in / ____ out Weight: ______ Exam (system-by-system): __________________________________________ Labs (relevant): __________________________________________________ Imaging: __________________________________________________________ ASSESSMENT (problem-based) # Problem 1: ______________________________________________________ # Problem 2: ______________________________________________________ # Problem 3: ______________________________________________________ PLAN (by problem) # Problem 1: ______________________________________________________ # Problem 2: ______________________________________________________ # Problem 3: ______________________________________________________ DISPOSITION DC planning: _____________________________________________________ Anticipated DC: ____/____/______ Signed: __________________________ Date: ____/____/______
Post-op progress note
Short, focused note for postoperative day rounds. POD number is the orienting field. Most surgeons expect this in two to four lines per system.
POST-OPERATIVE PROGRESS NOTE POD #______ Patient: ______________________ MRN: __________ Room: ______ Procedure: ____________________ Surgeon: ____________________ Date of surgery: ____/____/______ S: Pain ____/10 N/V: ____ Ambulating: ____ Tolerating diet: ____ O: T ____ HR ____ BP ____ SpO2 ____ I/O: ____ / ____ Wound: __________________________ Drains: ________________ Foley: ____ PIV: ____ Pertinent labs: ___________________________________________ A: POD #____ s/p _____________ , doing well/concerns: ____________ P: [ ] Continue current orders [ ] Advance diet [ ] D/C Foley [ ] D/C drain [ ] D/C PCA [ ] Pain control: ___________________________________________ [ ] PT/OT consult [ ] DC home [ ] DC to SNF Signed: __________________________ Date: ____/____/______
Behavioral health progress note (DAP)
DAP (Data, Assessment, Plan) is widely accepted in psychotherapy and counseling. Includes risk assessment and progress toward treatment plan goals, both required for most insurance reimbursement.
BEHAVIORAL HEALTH PROGRESS NOTE (DAP) Client: ______________________ DOB: ____/____/______ Session date: ____/____/______ Duration: ____ min Modality: __________ CPT: __________ Dx: ____________________________________________ D - DATA Presentation: _____________________________________________________ Mood: ______ Affect: ______ Risk (SI/HI): __________________________ Session content: __________________________________________________ ___________________________________________________________________ A - ASSESSMENT Progress toward treatment plan goals: _____________________________ Clinical impression: ______________________________________________ Risk assessment: __________________________________________________ P - PLAN Next session: ____/____/______ Homework / between-session: _______________________________________ Treatment plan changes: ___________________________________________ Clinician signature: ___________________ Date: ____/____/______
SOAP vs DAP vs BIRP for therapy:
- SOAP separates subjective from objective. Useful when there is a meaningful exam (med management).
- DAP combines subjective and objective into Data. Cleaner for talk therapy where the line between the two blurs.
- BIRP (Behavior, Intervention, Response, Plan) emphasizes what the therapist did and how the client responded. Common in substance use and group therapy.
Common mistakes on progress notes
- Cloning the prior note without meaningful update.Copy-forwarding is one of the top reasons payers deny claims. Each note must reflect today's visit, not yesterday's.
- No clinical reasoning in the assessment. Listing the diagnosis without explaining how you got there leaves the note legally weak. Include one or two sentences of reasoning.
- Plan that is not actionable."Continue current management" is not a plan if there is no current management documented. Specify medications, doses, follow-up timing, and patient education.
- Missing risk assessment in behavioral health. Every behavioral health note should include suicide and homicide risk assessment, even if the answer is clearly no. Without it, the note will not survive an audit.
Progress notes for AI scribe users
PatientNotes drafts the entire progress note from the visit conversation: the subjective from what the patient said, the objective from the exam findings you mentioned out loud or entered, the assessment from your spoken clinical reasoning, and the plan from what you told the patient. SOAP, DAP, and narrative formats are all supported. You review and sign rather than type from scratch, which moves note completion from after-hours charting to inside the visit itself.
Frequently asked questions
What is a progress note?
A progress note is a chart entry that documents a single encounter with a patient: what was discussed, what was found, how the clinician interpreted it, and what the next step is. Progress notes appear in the chart for every visit after the initial evaluation. They are billable, audit-relevant, and legally required for almost every reimbursable service.
What is the difference between SOAP, DAP, and BIRP notes?
SOAP (Subjective, Objective, Assessment, Plan) is the standard medical format. DAP (Data, Assessment, Plan) compresses subjective and objective into a single Data section and is common in social work and counseling. BIRP (Behavior, Intervention, Response, Plan) is used in therapy and substance use treatment to emphasize what the clinician did and how the client responded. All three are accepted by most payers; choose what your specialty and EHR support.
How long should a progress note be?
Length depends on the visit type. A focused outpatient follow-up can be 4 to 8 sentences. A daily inpatient progress note is typically a half-page to a page. A new behavioral health intake is 2 to 4 pages. The rule is that the note should be long enough to support the level of service billed and short enough that another clinician can read it in under a minute.
Are narrative progress notes still acceptable?
Yes. Narrative notes (free-text rather than structured SOAP) remain acceptable for most settings, especially when the clinician knows the patient well. Some payers and most EHRs prefer SOAP for clarity and templating, but the legal requirement is that the note documents the necessary elements, not that it follows a particular format.
Who can write a progress note?
Any licensed clinician treating the patient can write a progress note: physicians, NPs, PAs, RNs, therapists, social workers, dietitians, PTs, OTs, and SLPs. The note must be signed by the writer and, in some cases, co-signed by a supervising clinician. Trainees write notes that are reviewed and signed by their attending.
How quickly should a progress note be written?
Best practice is to complete the note before the next patient. Many EHRs and payers require notes to be signed within 24 to 48 hours. AI scribes like PatientNotes draft the note as you talk to the patient, so you can review and sign it at the end of the visit instead of in the evening.
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