Clinical template
Progress Note Template with Examples
A ward progress note answers one question: what is different since yesterday, and what are we doing about it today. It is not the outpatient SOAP page and it is not a discharge summary. Use the blank below for a daily inpatient note, then two fictional Canadian examples — medicine and post-operative.
Blank daily progress note
Copy this into the inpatient EMR or a Scribeberry template. Keep yesterday's problems, drop the ones that closed, and write today's plan in verbs the nurse and the evening covering resident can follow.
Ward progress note
Date / time: Day of admission: Author / service: Patient: [initials, age] | Code status / goals of care: Overnight / last 24 h events: Subjective (patient or nurse report): Vitals (range or current): BP HR RR Temp SpO2 (O2 device) I&O / weight / drains / wound: Exam (focused; abnormal first): Labs / imaging today (or 'none pending this morning'): Active issues 1. [problem] — status vs yesterday — plan for today 2. 3. Pending (tests, consults, disposition blockers): Disposition / estimated discharge needs: Discussed with:
Fictional patients
Examples on this page are made-up. They are not a substitute for your service's note standards or the inpatient chart. If you generate a progress note, read it against today's vitals and orders before you sign. Copy-forward is how wrong potassium values live for three days.
Progress note vs SOAP encounter note
Outpatient SOAP records one visit from scratch: chief complaint, full HPI, exam, assessment, plan. A daily ward note assumes the admission H&P already exists. Do not rewrite the social history every morning. Do not skip the overnight events. SOAP headings are fine on the ward if you treat S as interval history, O as today's vitals and exam, A/P as numbered active issues. The SOAP template page on this site is for clinic encounters. This page is for the inpatient day.
| Element | Ward progress note | Clinic SOAP |
|---|---|---|
| Time horizon | Last 24 hours vs the rest of the admission | This visit vs the cumulative chart |
| Subjective | Pain, sleep, diet, new symptoms, nurse overnight report | Chief complaint and HPI |
| Objective | Vitals trend, I&O, drains, focused exam, today's labs | Vitals and exam for this appointment |
| Assessment / plan | Each active inpatient problem and today's orders | Each visit problem and outpatient follow-up |
| What to omit | Repeating the entire PMHx | Hour-by-hour inpatient detail |
Systems vs problem-oriented
Some services chart by system (neuro, CVS, resp, GI, GU, ID, heme, endocrine, lines, prophylaxis). That works in ICU and on complex medical wards when many systems move at once. On a straightforward pneumonia day, problem-oriented is faster and easier to scan at 02:00. Pick one structure and keep it for the admission so the next note is comparable.
Either format still needs a plan that can be executed: stop IV antibiotics and start oral, hold lasix today, chase the Doppler, book PT for stairs. 'Continue current management' is only acceptable when nothing changed and you say so explicitly.
Example 1 — medicine day 3, decompensated heart failure
CTU progress note
68-year-old woman, Saskatoon. Admission day 3. Fictional.
2026-08-26 08:40. ADM day 3. CTU (R2 Nguyen / Dr. S. Patel). Joan O., 68F. Goals of care: full, confirmed with patient yesterday. Overnight: slept in 2–3 h stretches. 1.2 L urine on IV furosemide. No CP, no fever. Nurse: mild dry cough, O2 2 L NP (was 4 L on admission). S Feels 'lighter.' Orthophnea better. Still ankle swelling. Eating 50%. No dizziness on standing this morning. O Vitals: 118/70, HR 82 (AF known), RR 18, T 36.7, SpO2 94% 2 L NP (92–95 overnight). Weight 81.4 kg (−2.1 kg since admission). I&O last 24 h: in 1.4 / out 2.6. Exam: JVP 4 cm above sternal angle (was 8). Crackles bases, less than day 1. Pitting edema to mid-shin, improved. No calf pain. Heart irregular, no new murmur. Labs today: K 3.6 (was 3.4; replaced), Cr 128 (baseline ~95, was 140 day 1), NT-proBNP not repeated. CXR day 1 only. Active issues 1. Acute decompensated HF, HFrEF 35% known — net negative, O2 down. Plan: IV furosemide 40 mg BID today; daily weights; fluid restrict 1.5 L; K replacement protocol; try room air trial this afternoon. 2. AF, rate controlled on bisoprolol — continue. Anticoagulation: apixaban continued. 3. Rising Cr, improving — hold ramipril another day; recheck Cr/K tomorrow; GP already on ramipril as home med. 4. VTE prophylaxis — heparin 5000 units SC BID, continue while admitted. 5. Disposition — PT today for 2WW and stairs. Likely home day 5–6 if room air and weight stable. No homecare at baseline. Pending: echo (ordered, not done — chase). Room air trial. PT note. Discussed with MRP on morning rounds.
Example 2 — post-op day 2, colon resection
General surgery progress note
62-year-old man, Vancouver. Open right hemicolectomy for adenocarcinoma. Fictional.
2026-08-26 07:15. POD 2. General surgery (Dr. H. Gill). Daniel C., 62M. Full code. Overnight: pain 4/10 on PCA, used 8 mg hydromorphone IV / 24 h. Flatus x 1 at 05:00. No fever. JP 80 mL serosanguinous. Urine 0.6 mL/kg/h. S Nauseated with sips. Passing flatus, no stool. Abdominal pain controlled if he splints. Wants the catheter out. O Vitals: 132/78, HR 88, RR 16, T 37.4, SpO2 97% RA. I&O: in 2.1 (IV) / out 1.8. JP 80 mL. Foley in situ, clear. Exam: alert. Chest clear, incentive spirometry 1500 mL. Abdomen soft, incision clean, no erythema, bowel sounds present. No peritoneal findings. Calves soft. PCA in use. Labs: Hb 108 (was 112 POD 0), WBC 11.2, K 3.9, Cr 74. Active issues 1. POD 2 right hemicolectomy, uncomplicated — plan: sips to clear fluids if no vomiting; continue PCA, add PO acetaminophen 1 g q6h; out of bed TID; incentive spirometry. 2. Ileus risk — flatus started; no NG. If no flatus/stool by POD 4, reassess. 3. Foley — discontinue this morning if voiding trial ok. 4. JP — leave, output <100 and non-bilious. 5. VTE — sequential compression + heparin 5000 SC BID. 6. Oncology staging path pending — not a today issue; will be in discharge summary. 7. Diet / diabetes — home metformin held; sliding scale; diabetic diet when on solids. Pending: voiding trial. Pathology (not for today). Disposition: targeting POD 4–5 if eating, voiding, pain oral. Discussed with fellow.
Copy-forward and other ward failures
- Yesterday's exam left in place, including a drain that was pulled.
- Vitals copied from the first row of the flowsheet instead of the overnight range.
- Plan that says 'continue' when antibiotics were due to stop today.
- No mention of a rapid-response call because it happened after you wrote the note — add an addendum.
- Writing the discharge summary into the day-2 progress note, or writing a full HPI every morning.
- Leaving the same 'awaiting echo' line for four days without chasing it.
If the EMR copy-forward tool is on, the note is only valid after you have touched every line that could have changed: lines, oxygen, diet, code status, and the problem list. An addendum is better than a silent edit after the fact.
Dictate the daily progress note on rounds
Scribeberry takes bedside dictation or ambient audio and drafts today's interval note in your ward headings. Edit against the flowsheet, then Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a progress note in hospital?
A daily (or shift) inpatient record of interval history, vitals, focused exam, active problems, and today's plan. It assumes an admission note already exists. It is written so covering staff and the next day's team can see what changed.
Should ward progress notes use SOAP?
They can. Use S for interval symptoms and overnight events, O for today's measurements, and numbered A/P for active issues. Do not paste a clinic-style HPI. Systems-based notes are an alternative on ICU and complex medical services.
How often should a progress note be written?
Most medical and surgical wards expect a dated note each day the patient is admitted, plus an addendum after a significant event (fall, rapid response, new fever). Follow your hospital medical-staff rules; some step-down units require twice-daily notes.
Can Scribeberry write inpatient progress notes?
Yes. Pick a progress-note template, record rounds or dictate, and generate. You still reconcile vitals, I&O, and orders before signing. Custom templates can match CTU or surgical headings.
Templates
