The Inpatient Progress Note: A Practical Guide for NP and PA Students

Writing clear, concise, and accurate inpatient progress notes is a fundamental skill for Nurse Practitioner (NP) and Physician Associate (PA) students. Effective documentation ensures excellent patient care, supports medical decision-making, facilitates communication among the interdisciplinary team, and helps meet billing and regulatory requirements. This guide offers essential tips to help you develop this critical skill.

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Developing Your Documentation Style

NP and PA students must develop the skill of writing effective progress notes tailored to their clinical roles. NP students, especially, should transition from the documentation style typical of registered nurses by focusing on concise, pertinent data directly relevant to their specific service line and clinical decision-making.

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The Purpose of the Progress Note

Daily progress notes serve multiple key purposes:

• Document the patient’s response to treatment and update the plan of care during hospitalization

• Ensure continuity of care among providers across shifts and service lines

• Support accurate billing through appropriate diagnosis documentation

• Provide a rationale for medical decision-making

• Facilitate clear communication within the interdisciplinary care team

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Tip #1: Subjective Data

The subjective section should capture the patient’s report of symptoms and concerns. You may also include relevant input from family members or nursing staff. Avoid restating extensive past medical history or including your own interpretations or physical exam findings here. Remember, the progress note is a daily continuation of the consultation or history and physical note which encompasses more details. Think of the progress note just as the word implies, daily progress toward goals of care. 

Example:
The patient reports continued, substernal chest pain rated 4/10 since this morning, without shortness of breath or diaphoresis. No nausea or vomiting. The pain is described as a mostly constant ache that does not increase with movement or deep breath. The patient was given Maalox this morning with mild relief.

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Tip #2: Objective Data

The objective section includes measurable data such as:

• Vital signs and weight

• Laboratory results

• Diagnostic findings (e.g., chest X-ray, EKG)—consider embedding images of relevant studies to enhance documentation quality

• Your detailed physical exam findings

Example:
The patient is awake, oriented, and in no distress. No jugular venous distention (JVD) is noted. Lung sounds are clear; the patient is not on supplemental oxygen and respirations are unlabored. Heart rate is regular with no murmurs or rubs. No peripheral edema present. Abdomen is soft, non-tender with positive bowel sounds.

Include diagnostic reports from the day, such as chest X-ray (CXR) and EKG, directly in this section.

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Tip #3: Assessment and Plan

The Assessment and Plan (A/P) section is where you document billable diagnoses using ICD-10 codes, based on your clinical evaluation and current data. Select diagnoses that accurately reflect the patient’s condition and severity with as much specificity as possible. Each diagnosis should be paired with a clear treatment plan that addresses the patient’s acuity.

Example A/P:

• Chest pain: Possible cardiac etiology; patient has risk factors for CAD. High-sensitivity troponin normal; EKG non-ischemic. Plan: Obtain echocardiogram and plan for a treadmill nuclear stress test tomorrow to evaluate ischemic causes of chest pain. If this is normal, the patient can be discharged home with follow up in the cardiology clinic. 

• Dyslipidemia: Lipid panel is pending this morning. Patient currently on Crestor. Liver enzymes (AST/ALT) are within normal limits.

• Tobacco use: Counseled on cessation; referred to smoking cessation program.

Example A/P (Acute Heart Failure Patient):

• Acute on chronic HFrEF: Last echo one year ago showed LVEF 35%. Echo pending today. Continue IV Lasix 40 mg BID and Coreg 6.25 mg BID. Holding Lisinopril due to hypotension and elevated creatinine; will withhold spironolactone for same reasons. Consider starting SGLT2 inhibitor before discharge. Monitor intake/output and daily weights. Consider ICD placement and referral to cardiac rehab before discharge.

• Hypertensive heart disease with heart failure: Blood pressure currently low; continue monitoring.

• Obesity: BMI 45.

• Mild hypokalemia: Potassium 3.4; ordered 40 meq potassium replacement once. Goal potassium level is 4.0. BMP and magnesium labs ordered for the morning.

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Tip #4: Documenting Quality and Performance Measures

Document specific quality metrics required by your organization or accreditation programs, such as a ASCVD risk score to calculate risk for coronary disease, venous thromboembolism (VTE) prophylaxis, or antibiotic stewardship. Proper documentation supports patient safety initiatives, regulatory compliance, and quality improvement efforts.

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Tip #5: Organization and Precision

Keep your progress notes well-organized and focused on the key clinical issues your service is managing. The note should clearly communicate the daily plan to other hospital providers. Avoid unnecessary verbiage that may obscure important information or lengthen the note without adding value. Use bullet points and highlight changes in treatment in bold to make it easier for others to hone in on important points. 

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Conclusion

Mastering the inpatient progress note is a vital skill that improves patient care and interdisciplinary communication. By following these tips and practicing regularly, NP and PA students can develop clear, concise, and clinically relevant documentation habits that will serve them throughout their careers.