Infectious Disease Inpatient Progress Note

Date and time of service: [Service date and time]

Note type: ID Inpatient Progress Note

ID follow-up day: [Follow-up day number] (Include only if tracked by service)

Attending of record: [Attending name and credentials]

Author: [Author name and role]

Following for: [Infectious syndrome]; [Organism if known or pending]; [Suspected or confirmed source]; [Current antimicrobial therapy]; [Immediate clinical question]

(Omit sections with no relevant content rather than inserting placeholders; include explicit statements for safety-relevant missing data and key pending results.)

Interval Events

[Interval changes since last ID note] (Brief, 2–4 sentences. Include fever curve, localizing symptoms, clinical response to therapy [improved / stable / worsened], antimicrobial intolerance or toxicity, and key procedures or events affecting management. Label items as [new / stable / resolved]. If the patient could not be assessed, state this with brief reasoning.)

Assessment & Plan

(Organize by infectious syndrome. Order problems by acuity with highest threat to life first. Repeat the problem block for each active infectious issue.)

[Problem title: infectious syndrome — organism — source status]

[Clinical trajectory and supporting evidence] (State trajectory as [improving / stable / worsening] with pertinent data.)

Working diagnosis: [Diagnosis] ([confirmed / probable / suspected])

• Impact of new data: [How new microbiology or imaging results affect diagnosis and management]
• Antimicrobial plan: [Agent(s) with dose, route, frequency]; [continue / narrow / broaden / stop]; [rationale]; [intended duration and day 1 definition if applicable]; [reassessment timing for empiric therapy]
• Source control: [Status and recommendations for drainage, debridement, or device management]
• Diagnostics and monitoring: [Pending or planned tests that will change management]; [safety and efficacy monitoring plan with frequency]
• Stewardship checkpoints: [Criteria to de-escalate or discontinue]; [planned reassessment timing]; [intended total duration]
• Isolation: [standard / contact / droplet / airborne] (Include only if change recommended or clarification needed.)
• Discharge planning: [Anticipated therapy route]; [OPAT candidacy]; [outpatient follow-up] (Include only for patients approaching discharge.)

(Add additional problem blocks as needed.)

Current Antimicrobials

(List all active antimicrobial, antifungal, antiviral, and ID-managed prophylactic agents.)

• [Drug name] — [dose] [route] [frequency]; [Start date or Day #]; Indication: [linked problem]; Plan: [planned duration or reassessment trigger]; (Note changes in last 24–72 hours with brief rationale if applicable.)
• [Additional agents as needed]

Microbiology & Key Data

(Curate dated results that inform current management. Distinguish confirmed pathogens from likely contaminants with brief reasoning.)

Cultures: [Specimen source — collection date — status (final / preliminary / no growth to date) — organism and key susceptibilities — pathogen vs contaminant interpretation]

Non-culture diagnostics: [Test type — date — result and interpretation] (Include PCR, antigen, serology as relevant.)

Laboratory trends: [Relevant inflammatory markers, renal/hepatic function for dosing, therapeutic drug levels — dates and directional change] (Focus on values affecting management decisions.)

Imaging: [Study — date — key impression relevant to infection and evolution from prior]

Pending results: [Key pending tests — expected availability — how result will inform management] (Include explicit safety-relevant statements if essential cultures or studies are pending.)