Adult Inpatient/Observation Daily Progress Note (Problem-Oriented)

Date/Time: [Date and time of note]
Hospital Day: [HD#]
Location/Service: [Unit / Service]
Author: [Name, role]
Attending: [Name, credentials]

One-Liner: [Age]-year-old [sex/gender] with [key PMH] admitted for [admission diagnosis], currently [clinical trajectory]. (1–2 sentences orienting to why admitted and where headed.)

Interval Events

(Include only if events occurred or explicitly confirmed none. If confirmed none, write: "No acute overnight events." If not confirmed, omit section entirely.)

• [Overnight events or acute changes]
• [Procedures performed]
• [Key consult recommendations and whether implemented]
• [Significant new results that changed management]
• [Material medication changes]

Subjective

[Patient-reported symptoms and change since yesterday; functional status including diet, ambulation, pain control; goals or preferences affecting plan] (Use direct quotes only for salient concerns or refusals. If unable to interview, state why.)

Objective

Vitals: [Current vitals with 24h ranges for abnormal parameters; oxygen delivery if applicable]

Exam: [Focused findings relevant to active problems] (State if limited or deferred and why.)

Data: [Key lab trends in yesterday→today format; new imaging with clinical interpretation; pending cultures; consultant recommendations by service name] (Do not paste full reports. Include only data informing today's decisions.)

Assessment & Plan

(Organize by problem in decreasing severity and discharge impact.)

[Problem title] ([improving / worsening / stable])

Assessment: [Current status, working diagnosis with supporting data, differential if uncertain]

Plan: [Diagnostics, therapeutics, monitoring, escalation thresholds, discharge criteria for this problem]

Today: [Key change or action for this problem]

(Repeat for each active problem.)

Inpatient Safety

(Include only if actively managed or updated today.)

• [VTE prophylaxis with rationale if non-standard]
• [Code status if changed or discussed]
• [Foley/line necessity and removal plan]

Disposition

EDD: [Expected discharge date / pending clinical course]

Destination: [Home / home with services / SNF / rehab / other]

Barriers: [Medical, functional, and social barriers with responsible owners]

Tasks today: [Specific actions with responsible parties]

Pending results: [Results to follow after discharge and communication plan]

(If selecting code by time, include attestation: total minutes on date of service and qualifying activities performed.)