Progress notes

Best practices. Therapies that researchers have found to be effective for a disorder. Chart notes (or progress notes). Notes in a client s chart that document treatment progress. 

Akamine EK. 1952. Toxicity of ethylene dibromide to white rats. Hawaii Agricultural Experiment Station of the University of Hawaii, Progress Notes No. 83, July 1984. 1-4. 

In metastatic carcinoma continue until progression noted... 

Booklets, videocassettes, or audiotapes should never take the place of a personal encounter. A dated and signed progress note, including these details, is usually considered sufficient documentation. 

Following each of your reviews, write a brief summary of your progress. Note progress made toward your goals, things that have changed, and problems you have encountered. 

The documentation will occur via a patient chart. Subjective patient information and objective laboratory data will be stored in the chart. Assessments of patients during the clinic visit will be documented in pharmacy progress notes contained in the chart. Acceptance of pharmacy recommendations by physicians will constitute an order change, and this will be documented in the patient record as well. Lasdy, patient... 

One of the pharmacists began to call on physicians so that he could promote the services face to face. The pharmacist met with some of the local pharmaceutical company representatives to find out which physicians should be identified as key targets for the promotional efforts. Also, the pharmacy created a physician newsletter entitled, Progress Notes, that would be sent every other month to key physicians. The format of the newsletter includes sections on new drug updates, clinical pearls, and message updates about Care-Rite Pharmacy. The first newsletter was dedicated to the Pharmacy Check-up Service. 

AMA-BCDSP Pilot Drug Surveillance Study, Progress Note No. i, John Adriani Papers, NLM, box 28, folder 2,1. 

Clarify all text items, for example adverse events, concomitant medications, physical examinations, ECG, progress notes and so on. 

For every patient with a serum drug concentration ordered, the primary pharmacist writes a Clinical Pharmacokinetics note in the progress notes section of the patient s chart within 24 hours for normal or subthe-rapeutic concentrations. For supratherapeutic drug concentrations, the medical team is notified immediately if clinically warranted and a chart note written within 12 hours after the concentration was reported. The chart note contains all relevant patient information and pharmacokinetic parameters necessary to provide dosing and monitoring recommendations. ... 

McClennan et al. conducted a prospective 2-month intervention study to determine clinical outcomes associated with pharmacist interventions at a tertiary referral cancer institute in Australia. Clinical pharmacists documented clinical interventions and relevant patient information which were assessed by an independent pharmacist. Members of the healthcare team reviewed and discussed medical progress notes to determine outcomes. Of 674 total interventions that were documented during the study, outcomes were assessed for 10% of the interventions reported 90% of the interventions led to documented clinical benefit. Pharmacist interventions most frequently consisted of initiating changes in drug therapy associated with antiemetic, antimicrobial, and analgesic agents. 

Upon admission, the cancer patient is asked to complete a survey to assess their current pain situation. A copy of the form is provided in the article. Every 8 hours, a nurse records three pain-intensity values on the bedside flow sheet. After a patient is seen and evaluated, recommendations are conveyed orally to the prescribing physician or documented in the progress notes. Verbal orders are obtained when rapid changes are needed to analgesic orders. An education series is provided every month by the ADS attending physician or pharmacist to cover basic approaches to management of cancer-related... 

The primary care physician or the nurses are generally assigned the responsibility for documenting the progress note. According to Ouslander, Osterweil, and Morley (1998), the following information must be clearly documented in order to accurately monitor medications ... 

The pharmacist updates the patient s medical and/or pharmacy record with information concerning patient progress, noting the subjective and objective information which has been considered, his/her assessment of the patient s current progress, the patient s assessment of his/her current progress, and any modifications that are being made to the plan. Communications with other healthcare providers should also be noted. 

Monitors are expected to review CRF and source documents with particular attention to potential safety problems. On the CRF, the adverse events section and laboratory results section are reviewed for important findings. Often, relevant notes are made by the investigator in the comment section of the CRF. In source documents, safety issues may be uncovered in the progress notes of... 

C) medical opinions, diagnoses, progress notes, and recommendations. 

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