Student Inpatient Progress Note

Student Inpatient Progress Note

Date: [date of service]
Time: [24-hour time]
Patient: [name, MRN, room]
Age: [age]
Hospital Day: [HD#; include POD# if post-operative]
Service: [primary team/service]
Author: Medical Student

One-Line Summary: [age/sex + key comorbidities + reason for admission + current status/trajectory] (Update daily; keep clinically dense.)

What Changed Today

• [Interval events and decision-driving changes from the last 24 hours] (Include overnight events, hemodynamic/respiratory changes, acute symptoms, significant vital sign or I/O trends, new results that changed management, new interventions with medication starts/stops/procedures/consult recommendations, and discharge updates. If no significant change, document stability with specific anchors such as stable vitals, no PRNs, unchanged O2 requirement.)

Subjective

[Patient-reported symptoms and functional status since last note] (Include pain, breathing, ambulation, sleep, diet tolerance; pertinent positives and negatives tied to active problems; relevant nursing updates including PRNs given and response. If patient cannot provide history, state the limitation and alternate source. Include goals-of-care updates only if newly clarified or changed.)

Objective

Vitals: [Tmax, HR range, BP range, RR, SpO2 on specified O2 support; note trends when clinically meaningful]

I/O: [24-hour intake, output, net balance; include urine output if relevant to active problems] (If not documented, state "I/O not recorded.")

Exam: [Focused physical exam by system] (Document only elements personally performed. Include general appearance, mental status, and systems relevant to active problems. Specify if any component was limited or refused.)

Data: [New or decision-relevant results only] (Highlight abnormal labs with trends using yesterday → today format when relevant; for cultures include organism and susceptibilities if available; for imaging include study date and summarized impression; for consults include new recommendations. Omit if no new data.)

Lines/Drains/Airways: [type, location, day of placement, indication status] (Omit if none present.)

Assessment & Plan

[Global assessment linking overall trajectory to today's priorities] (Optional opening sentence.)

[Problem Name] – [improving / worsening / stable]

Assessment: [Key data supporting working diagnosis; include differential if uncertain, focusing on plausible and high-risk alternatives]

Plan: [Diagnostics, therapeutics with new starts/stops/dose changes, antibiotic day counts if applicable, consults with attribution, monitoring parameters, contingencies as "if X, then Y"] (List as bullets or narrative as appropriate.)

(Add problem blocks as needed. Order by acuity: highest risk first, then active inpatient issues, then relevant stable chronic conditions. For stable chronic issues affecting inpatient safety such as anticoagulation, insulin, or seizure medications, include brief maintenance statement within relevant problem or as separate line item. Include VTE prophylaxis status and code status if newly confirmed or in question.)

Disposition

[Expected discharge timeframe, clinical milestones needed, placement needs, barriers, pending items] (Address O2 requirement, PO tolerance, PT/OT clearance, and other discharge criteria as relevant.)

(If information expected for a problem is missing or unknown, explicitly state "not documented" or "unknown" rather than leaving blank. Do not document exam findings not personally performed or infer events not verified.)