HOSPITALIST PROGRESS NOTE

Patient: [Name]
Date of birth or ID: [Identifier]
Location: [Unit and room]
Date: [Date]
Hospital day: [Day number, and the reason for admission]
Attending: [Name]
Author: [Name, credentials]

INTERVAL EVENTS
Overnight: [Events, rapid responses, cross-cover calls, new orders]
Since the last note: [Results back, consultant recommendations, procedures done]

SUBJECTIVE
Patient report: [Symptoms today compared with yesterday, pain, sleep, appetite, bowels and bladder, mobility]
Team and family concerns: [Issues raised by nursing, therapists, or family]

OBJECTIVE
Vital signs: [Current values and 24-hour ranges; oxygen device and flow]
Intake and output: [24-hour intake, urine output, net balance, drains, stools]
Weight: [Today's weight in kg and lb, and the change since admission]
Examination: [Focused findings by system, and what changed since yesterday]

DATA
Labs: [Key values with their trend, such as white count, hemoglobin, creatinine, potassium]
Microbiology: [Cultures, sensitivities, and what is still pending]
Imaging and tests: [New results, and what they change]
Medications: [Antibiotic day number, new or stopped medications, as-needed use]

ASSESSMENT AND PLAN
Summary: [Age, sex, key history, reason for admission, hospital day, and whether better, the same, or worse]
Problem 1: [Problem, status today, and today's plan]
Problem 2: [Problem, status today, and today's plan]
Chronic conditions: [Home medications continued, held, or changed, with reasons]

DAILY CHECKLIST
VTE prophylaxis: [Agent and dose, mechanical, or not indicated and why]
Lines, tubes, and drains: [Each device, its day number, and whether it is still needed]
Diet: [Diet ordered, or NPO and why]
Activity: [Mobility goal, therapy, fall risk]
Code status: [Current code status, and when it was last confirmed]

DISPOSITION
Expected discharge: [Date and destination]
Barriers: [Medical, functional, social, or pending results]
Communication: [Patient, family, and team members updated today]

Signed: [Clinician name, credentials, date and time]