Emergency Department Observation Progress Note

Date/Time of Note: [Date and time of this progress note]

Author: [Author name and credentials]

Patient Location: [Current ED observation bed/area]

Observation Start Date/Time: [Date and time observation status began]

Observation Day: [Day and hour of observation]

Primary Observation Indication: [Primary clinical reason for observation]

Current Working Diagnosis: [Most likely diagnosis/es at this time]

Interval Summary

[Concise interval course summary] (1–3 sentences summarizing patient trajectory since last evaluation: state whether the patient has [improved / worsened / remained stable], any significant interval events, and what disposition decision remains pending. If no changes, explicitly state the patient remains stable with no interval events.)

Subjective

[Patient-reported status and interval symptoms relevant to observation indication] (Brief paragraph. Document [better / worse / same], pertinent interval symptoms, response to therapies, and functional status affecting disposition such as oral intake, ambulation, and pain control. Include a direct quote only if it clarifies ambiguity. If the patient cannot provide history, state the reason and list collateral sources used.)

Objective

Vitals: [Current vital signs with notable trends or ranges during observation; oxygen requirements if applicable]

Exam: [Focused physical examination findings relevant to observation indication] (Document pertinent positives and negatives only. State any limitations to exam.)

Interval Data: [Key laboratory results, imaging interpretations, EKG/telemetry findings, and point-of-care test results obtained during observation] (Emphasize trends and clinically significant values. Note official read status for imaging. Explicitly list any pending studies with expected timing. If no new results since prior assessment, state this directly.)

Therapies/Response: [Interventions administered and patient response] (Include medications, IV fluids, respiratory treatments, procedures as relevant. Note any adverse effects.)

Consults: [Consultant recommendations received and whether implemented] (Omit if no consults involved.)

Assessment & Plan

(Problem-oriented list ordered by acuity and disposition impact. Primary observation indication should appear first. For each problem, embed medical necessity by stating what risk prevents safe discharge, what is being monitored or treated, and what data or response is needed to finalize disposition.)

[Problem 1 – Primary Observation Indication]: [improved / worsening / stable / resolved]

[Brief assessment synthesizing symptoms, exam, and interval data for this problem. Include active differential only if driving testing or disposition uncertainty.]

Plan: [Diagnostics to obtain, therapeutic changes, monitoring requirements]

Disposition criteria: [Specific criteria for discharge vs. admission vs. continued observation; include what data or timeframe is needed]

[Problem 2]: [improved / worsening / stable / resolved] (Include additional problems only if they affect current management or disposition.)

Plan: [Diagnostics, therapies, monitoring]

Disposition criteria: [Problem-specific criteria]

Disposition

Current Decision: [Continue Observation / Discharge from Observation / Admit Inpatient / Transfer]

[Disposition rationale] (For continued observation: state what is pending, anticipated timeframe, and when next reassessment will occur. For discharge: confirm clinical stability, key results reviewed and acceptable, follow-up arranged, and return precautions reviewed with patient. For admission: state clinical rationale and what inpatient-level care is required.)

Handoff/Communication: [Relevant discussions with patient/family, nursing, consultants, or receiving team] (Include interpreter use if applicable. Omit if no significant communication to document.)

(This note captures interval changes only. Do not copy-forward from initial ED evaluation or observation H&P. If essential information is missing and affects safety or disposition, document explicitly. Ensure note is clearly dated, timed, and authenticated.)