Hospitalist Progress Note Template

TL;DR

• When to use: Daily progress notes, morning rounds documentation
• What it includes: Overnight events, current status, updated A&P

Template

DAILY PROGRESS NOTE

Date: [XX/XX/XXXX]
Hospital Day #: [XX]
Attending: [XX]

OVERNIGHT EVENTS:
[ ] Uneventful night
[ ] Events: [XX]
- Nursing calls: [XX]
- Vitals instability: [XX]
- Code/rapid response: [XX]
- New symptoms: [XX]
- Interventions: [XX]

SUBJECTIVE:
Patient reports: [symptoms, concerns, sleep quality, pain level]
Current complaints: [XX]
Overnight symptoms: [XX]

24-HOUR SUMMARY:
- Pain: [current level/10, trend]
- Sleep: [good/fair/poor]
- Appetite: [XX% of meals]
- Mobility: [ambulating/bed rest/PT working with]
- Bowel function: [last BM, any issues]
- Urinary function: [voiding/foley output]

OBJECTIVE:

Vitals (current/24hr range):
T: [XX] (Tmax [XX])
HR: [XX] ([XX]-[XX])
BP: [XX/XX] ([XX/XX]-[XX/XX])
RR: [XX]
SpO2: [XX]% on [RA/O2 device at XX L]

Trending Data:
- Weight: [XX] kg (admission: [XX] kg, change: [+/-XX] kg)
- Net I/O (24h): [XX] mL
- Glucose range: [XX]-[XX]

Physical Exam:
General: [alert, oriented, comfortable/in distress]
CV: [RRR, no murmurs, JVP XX cm]
Resp: [lung sounds, work of breathing, O2 requirement]
Abd: [soft, BS+, any tenderness]
Ext: [edema grading, pulses]
Neuro: [mental status, focal findings]
Lines/Drains: [PIV/central line day XX, foley day XX, drains]

Pertinent Labs:
[Today vs yesterday comparison]
WBC: [XX] -> [XX]
Hgb: [XX] -> [XX]
Cr: [XX] -> [XX]
[Other relevant trending labs]

Micro:
- Cultures: [pending/results]
- Antibiotics day: [XX]

Imaging/Studies:
[New studies and results]

ASSESSMENT & PLAN:

Overall: [XX]-year-old [male/female], hospital day #[XX], admitted for [primary diagnosis]. [Current trajectory: improving/stable/worsening]

Problem #1: [Active problem] - [Improving/Stable/Worsening]
- Assessment: [Current status, response to treatment]
- Plan:
  - [Continue/adjust/add intervention]
  - [Monitoring plan]
  - [Pending workup]

Problem #2: [Active problem] - [Status]
- Assessment: [XX]
- Plan:
  - [XX]

Problem #3: [Chronic condition] - [Status during admission]
- Assessment: [XX]
- Plan:
  - [Continue/hold/adjust]

PROPHYLAXIS:
- DVT: [current regimen/any changes]
- GI: [if indicated]
- Glucose: [current management]

LINES/TUBES/DRAINS:
- [Line type]: Day [XX], [date placed], [plan for removal/continuation]

DISPOSITION:
- Anticipated discharge: [date or "when criteria met"]
- Barriers to discharge: [XX]
- Discharge needs: [home health, PT/OT, equipment, follow-up]
- Care coordination: [social work, case management updates]

Code Status: [Full code/DNR/DNI] - [unchanged/updated]

[Provider signature block]

Why This Works

Overnight events upfront: Starting with overnight events ensures covering team observations are captured and prevents missed information from sign-out. It also flags acute changes needing immediate attention.

Trending data format: Showing vital signs as ranges and labs as day-over-day comparisons quickly communicates trajectory. A single number is a data point; trends tell the clinical story.

Problem-status pairing: Adding “Improving/Stable/Worsening” next to each problem forces explicit clinical assessment. This prevents autopilot documentation and catches early clinical deterioration.

Filled Example

[SYNTHETIC EXAMPLE - Not a real patient]

DAILY PROGRESS NOTE

Date: [XX/XX/XXXX]
Hospital Day #: 3
Attending: [XX]

OVERNIGHT EVENTS:
[X] Events:
- 02:00: Called for HR 110s, patient anxious, given PRN lorazepam with effect
- No other interventions required

SUBJECTIVE:
Patient reports feeling "much better" today. Breathing easier, able to lie flat overnight.
Current complaints: Mild fatigue, ready to go home
Overnight symptoms: Anxiety episode at 02:00, resolved

24-HOUR SUMMARY:
- Pain: 0/10
- Sleep: Fair (interrupted by anxiety episode)
- Appetite: 75% of meals
- Mobility: Ambulating to bathroom independently
- Bowel function: BM yesterday, no issues
- Urinary function: Voiding spontaneously

OBJECTIVE:

Vitals (current/24hr range):
T: 36.8 (Tmax 37.2)
HR: 78 (72-110)
BP: 128/76 (118/68-142/84)
RR: 16
SpO2: 96% on RA

Trending Data:
- Weight: 84.2 kg (admission: 88.0 kg, change: -3.8 kg)
- Net I/O (24h): -1,200 mL
- Glucose range: 142-186

Physical Exam:
General: Alert, oriented, comfortable, no distress
CV: RRR, no murmurs, JVP 6 cm (down from 12 cm on admission)
Resp: Clear bilaterally, no crackles (previously had bibasilar crackles)
Abd: Soft, NT, BS+
Ext: Trace pedal edema (down from 2+ bilaterally)
Neuro: A&Ox3, no focal deficits
Lines/Drains: PIV right forearm day 3, patent

Pertinent Labs:
BMP today vs admission:
Na: 138 -> 140
K: 4.2 -> 3.8 (repleted)
Cr: 1.4 -> 1.2 (baseline 1.1)
BNP: 1,850 -> 620

ASSESSMENT & PLAN:

Overall: 72-year-old male, hospital day #3, admitted for acute decompensated HFrEF. Clinically improving with good diuretic response.

Problem #1: Acute decompensated heart failure - Improving
- Assessment: Net negative 3.8 kg, JVP normalized, crackles resolved, BNP trending down
- Plan:
  - Transition to PO furosemide 60mg BID (up from home dose of 40mg daily)
  - If tolerates PO diuresis today, discharge tomorrow
  - Strict 1.5L fluid restriction
  - Low sodium diet education

Problem #2: Hypokalemia - Resolved
- Assessment: K 3.8 after repletion, likely diuretic-induced
- Plan:
  - Continue KCl 20 mEq daily with diuretic
  - Recheck BMP tomorrow

Problem #3: T2DM - Stable
- Assessment: Glucose 142-186 on home metformin + sliding scale
- Plan:
  - Resume home regimen at discharge
  - A1c pending (last was 7.2%)

[...additional problems...]

DISPOSITION:
- Anticipated discharge: Tomorrow if PO diuresis effective
- Barriers to discharge: None currently
- Discharge needs: Home health for CHF monitoring x2 weeks, scale at home
- Care coordination: Case management arranged VNA referral

Code Status: Full code - unchanged

Checklist

• Hospital day number documented
• Overnight events summarized from nursing/cross-cover
• Weight trend and net I/O documented
• Labs compared to prior day showing trajectory
• Each active problem has status (improving/stable/worsening)
• Discharge criteria and barriers explicitly stated
• Line/tube days documented with removal plan
• Code status confirmed unchanged

---

Last reviewed: 2026-01-20. Clinical content based on society guidelines, FDA labeling, and pivotal trials available at review date. Verify against current sources before clinical use.