A Hospital Progress Note is a dated and signed record documenting inpatient clinical observations, vital signs, and treatment plans, built with Template.net's AI-powered progress note builder. It is written by a wide range of healthcare practitioners including nurses, physicians, and allied health professionals to accurately record patient status after each hospital encounter.
A Hospital Progress Note is a dated and signed record documenting inpatient clinical observations, vital signs, and treatment plans, built with Template.net's AI-powered progress note builder. It is written by a wide range of healthcare practitioners including nurses, physicians, and allied health professionals to accurately record patient status after each hospital encounter.
How to Create a Hospital Progress Note for Free?
Creating a professional Hospital Progress Note is quick and straightforward.
- Customize a Free TemplateStart with this free editable and printable hospital progress note template and personalize it for documenting inpatient assessments, vital signs monitoring, or clinical treatment plans. (or )
- Generate an On-Brand Hospital Progress Note with AIDescribe the hospital encounter you just completed or upload your existing clinical notes or care summary, and AI will build the actual editable note with identification fields and narrative drafted from what you provided, ready for review, correction, and signature.
- Edit in the HTML5 EditorAdjust the patient name, date of birth, room and bed, time of observation, primary diagnosis, attending physician, allergies, other precautions, clinical observations, and the assessment summary, plus the header with hospital logo and name and footer with hospital unit and telemetry services in the drag-and-drop editor.
- Download a Printable PDFDownload the finalized note as a printable PDF to file in the patient’s record, hand to the care team, or keep for your clinical documentation.
Hospital Progress Note Observations and How Each One Is Recorded
This template already lays out patient identification fields, a safety screen, and subjective and objective observations, and the list below sets out how each entry is actually recorded.
Document these observations the way each one is normally recorded — patient identification details including name, DOB, date, room/bed, time, primary diagnosis, attending physician, allergies, and precautions (entered as labeled fields), safety screen status (selected from checkboxes such as stable, fall risk, isolation, DNR/DNI), subjective patient status (ticked from a checklist like resting quietly, no new complaints, pain controlled, anxious/agitated), objective clinical findings (marked from checkboxes for WNL per system, vitals stable, dressing clean, labs pending), temperature (chosen from options: normal, febrile, hypothermic, fluctuating), blood pressure status (checkboxes for WNL, hypertensive, hypotensive, orthostatic), heart rate status (selected from regular, tachycardiac, bradycardiac, irregular), respiratory rate status (checked eupneic, tachypneic, labored, apneic episodes), oxygen saturation (entered as RA ?95%, O2 supplement, desaturating, CPAP/BiPAP), neurological status (ticked alert and oriented x3, confused/lethargic, pupils PERRLA, motor deficit, seizure precaution), respiratory assessment (checkboxes lungs clear bilaterally, cough/sputum, diminished breath sounds, crackles/wheezes, O2 stable), cardiovascular assessment (noted S1 S2 audible, pulses palpable, edema present, murmur/gallop, capillary refill <3 seconds), gastrointestinal/genitourinary status (checked bowel sounds present, abdomen soft/non-tender, vomiting/diarrhea, voiding adequate, incontinent), treatment plans and clinical orders (marked from oral meds, IV meds, IV fluids, oxygen therapy, wound care, labs CBC/CMP, labs cultures, imaging XR, imaging CT/MRI, PT/OT consult, dietary orders, strict intake/output, venous thromboembolism prophylaxis, fall precautions, skin care, respiratory therapy, social work, case management, rehabilitation evaluation, discharge planning, or other noted in free text), and clinician signature with date and time (signed on a line).
