Inpatient Daily Progress Note

(Use APSO format. Keep note concise and action-oriented. Omit sections or subsections not clinically relevant to avoid note bloat. Use explicit placeholders only when absence of information is safety-critical. Do not carry forward unchanged exam or assessment text without re-verification.)

Date/Time: [date and time of service]

Hospital Day: [HD#, with POD# or ICU day if applicable]

Location/Service: [unit/bed and team]

Provider: [name, credentials]

Attending: [if different from author]

One-Liner: [Age, sex, key comorbidities affecting decisions, admitting diagnosis, current clinical frame] (Keep to one concise sentence.)

Assessment & Plan

(List active problems from highest to lowest acuity/risk. For each, include status, brief supporting evidence, and actionable plan items. Use action verbs: start/stop/continue/increase/decrease/hold/recheck/consult. Document reasoning when changing or withholding expected therapy.)

[Problem 1]: [concise problem label] — [improving / stable / worsening]

[Key supporting evidence and brief clinical reasoning if diagnosis uncertain or therapy changed]

• [Action item with specific intervention]
• [Action item]
• [Monitoring or contingency plan if explicitly decided]

[Problem 2]: [concise problem label] — [improving / stable / worsening]

[Supporting evidence and reasoning if needed]

• [Action item]
• [Action item]

[Additional Problems]

(Add problems as clinically necessary, following the same format.)

Global Care Items

Code Status: [current status and any discussions or changes] (If not yet confirmed: [Code status not yet confirmed — verify today].)

VTE Prophylaxis: [pharmacologic/mechanical plan or contraindication with reason]

Disposition: [estimated discharge timeframe, current barriers, destination and required services if known]

Interval Events

[Overnight events; new or resolved symptoms; diet tolerance; mobility; sleep; clinically relevant PRN use] (Do not include a full review of systems. If patient unable to provide history, note the limitation and alternative source used.)

Objective

Vitals: [24h ranges and most recent with trends; O2 delivery method]

I/O: [net 24h and weight trend if volume status relevant] (Omit if not applicable. If safety-critical and missing: [Overnight I/Os not recorded — obtain now].)

Exam: [Focused findings by system supporting active problems; document today's exam only] (Remove non-contributory systems; avoid copying forward unchanged normals.)

Data: [Pertinent labs with trends and interpretation; new micro results; new imaging with clinical meaning; pending studies] (Include only clinically relevant results.)

Lines/Devices: [Type, day#, indication, concerns, removal plan for each] (Omit if none present.)