Progress note template
A progress note answers one question for the next reader: what has changed since the last entry, and what are we doing about it. This page gives a blank progress note, an invented inpatient day-3 example, the common errors, and which ClearPass structure suits a progress note, including where it fits less well.
What a progress note is for
Progress notes are the running story between the admission or first assessment and discharge or the end of a treatment course. They are read quickly, often at night by someone covering. That reader needs the trend and today's plan, not the whole history again.
A good progress note leads with the interval: symptoms since the last review, events overnight, new results. It then gives today's findings and an assessment for each active problem, each with its own plan. Many services use SOAP headings for this; others prefer a problem-based layout. Either works if the change since last time is obvious.
Blank progress note
PROGRESS NOTE
Date / day of admission or treatment: [ ]
Reviewed by: [ ]
Interval history (since last review):
Events / new concerns:
Current treatment and response:
Today's findings:
Observations and trend:
Examination:
New results:
Assessment and plan by problem:
1. [problem] - status: better / same / worse
Plan:
2. [problem] - status:
Plan:
Discharge planning / next review:
Discussed with: [patient / family / team]
Filled example: day 3 of a pneumonia admission
Day 3 of admission, community-acquired pneumonia, right lower lobe. Interval: breathing easier, cough now productive of less sputum. Eating half of meals. Slept overnight. No chest pain. One fever spike to 37.9 yesterday afternoon, none since. Current treatment: day 3 IV antibiotics per local protocol, oxygen weaned off yesterday evening. Observations: HR 88 (from 110 on admission), RR 18, SpO2 95% on air, BP stable, afebrile 18 hours. Exam: reduced air entry and crackles right base, improved from admission. Calf soft. Results: CRP 96 (from 210), WBC 11.0 (from 17.8), creatinine back to baseline. 1. Pneumonia - improving. Plan: switch to oral antibiotics today to complete the course (team decision); mobilise with physiotherapy; repeat CRP in 48 hours. 2. Acute kidney injury on admission - resolved. Plan: restart ramipril tomorrow if creatinine stable. 3. Reduced oral intake. Plan: dietitian review, weigh twice weekly. Discharge: possible in 48 hours if afebrile, eating and mobile. Plan discussed with patient and daughter.
Errors that make progress notes hard to follow
- Copying yesterday's note forward so old findings look current.
- Numbers without a trend. CRP 96 means little; CRP 96 from 210 tells the story.
- A single overall plan when there are several problems, so it is unclear which action belongs to which issue.
- Omitting what was discussed with the patient or family, which matters when expectations differ later.
- No stated criteria for discharge or escalation.
Using ClearPass for progress notes
The best fit is the Follow-up structure. It leads with what has changed since the last visit, then current treatment and adherence, then today, which is the logic of a progress note. For a patient with several active issues, the Problem list structure is often better: a numbered list of problems, then each one with its own assessment and plan, like the example above. SOAP also works if your service expects it.
Be realistic about where ClearPass helps. It is built around a conversation with a patient, so it works well for clinic reviews and bedside discussions. A ward round where most of the thinking happens at the notes trolley is different: dictate a short summary in the browser or type your bullet points, and ClearPass arranges them under the chosen headings. Results can be photographed from a lab printout and read into the note. Every draft is reviewed and corrected by you before it goes into the chart, and it does not connect to the hospital EMR. For outpatient reviews, the follow-up note template is more specific.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
Is a progress note the same as a SOAP note?
A progress note is a purpose; SOAP is one format for it. Many progress notes use SOAP headings, others use a problem-based layout.
How often should inpatient progress notes be written?
That depends on your service's policy and the patient's condition. At minimum, write one whenever the assessment or plan changes.
Which ClearPass structure should I choose for a ward patient with many problems?
Problem list. It numbers the active problems and gives each its own assessment and plan.
Can ClearPass see the previous day's note?
Notes stay in your browser on your device. You can open an earlier note from History and paste the relevant parts into today's case.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
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