Cardiology Inpatient Progress Note

Daily Cardiology Inpatient Progress Note

Date: [date and time of service]

Hospital Day: [HD# and post-procedure day if applicable]

Service: [Cardiology subspecialty service]

Author: [name, role, contact]

Summary

[One-sentence summary including age, sex, key cardiac diagnosis, relevant comorbidities, reason for admission, and current trajectory; include support level when relevant such as ICU status, vasoactive support, mechanical circulatory support, or oxygen/ventilation] (Keep this strictly today-focused; avoid restating admission history.)

Interval History

[Concise narrative of events and changes since last cardiology assessment] (Include overnight events such as chest pain, dyspnea, hemodynamic changes, rapid responses; telemetry alerts; diuresis issues if volume management is active; procedures completed since prior note; patient-reported symptoms relevant to decisions. If history is limited, state the source and limitations. Focus on what changed since the last note.)

Objective

(For key monitoring domains—hemodynamics, telemetry, and diuresis response—explicitly state presence or absence of findings rather than omitting the section. If a key datum is unavailable, document that it is missing and the plan to obtain it.)

Vitals/Hemodynamics: [Current vitals and relevant trends; invasive hemodynamics with timestamp if monitored; vasoactive support with doses if applicable] (Explicitly state if no invasive monitoring or no abnormal hemodynamics noted.)

Telemetry: [Predominant rhythm, rate range, and meaningful events] (Always include an explicit statement about monitoring status and events, such as "no events overnight" or "not on telemetry.")

Volume Status: [24h intake/output, net balance, weight trend with method, diuretic doses and response interpretation] (Include only when heart failure or active volume management is relevant; omit entirely otherwise.)

Exam: [Focused cardiopulmonary and volume exam including JVP, lung sounds, cardiac rhythm/murmurs, edema, perfusion, and access site if post-procedure]

Data: [Pertinent labs with brief interpretation, new or changed ECG findings, relevant imaging updates, recent cath data if applicable] (Curate to findings that impact today's management. Note any missing key data and plan to obtain.)

Assessment & Plan

(Number problems by acuity. For each cardiovascular problem: state current status with supporting data, medication changes with rationale, monitoring plan, pending diagnostics, and discharge-relevant milestones. Include non-cardiac comorbidities only if they impact cardiology management or disposition.)

1. [Problem name] — [improving / stable / worsening] ([1–3 supporting data points]). [Medication changes with dose/route and rationale. Monitoring and diagnostic plan. Contingencies if applicable. Discharge milestone for this problem.]
2. [Problem name] — [status] ([supporting data]). [Plan as above.]
3. [Additional problems as needed]

Disposition

[Anticipated discharge timing and destination; barriers or pending requirements; follow-up needs including clinic appointments, rehab, and labs; key medication plan at discharge] (Explicitly state what must occur in the next 24 hours to enable disposition.)

Electronic Signature: [name, credentials, date/time, contact]

Attending Attestation: [patient- and encounter-specific attestation statement with date/time] (Include if on a teaching service.)