Progress Note

OVERALL_INSTRUCTIONS

Write a complete letter, not a condensed summary: the reader was not present for the encounter and relies on this letter alone. Do not summarize away concrete, discrete details that were explicitly stated in the source material -- specific dates, times and durations, appointment/follow-up arrangements, named people or facilities, doses/routes/frequencies of medications and supplements, and monitoring instructions. If such a detail is stated, carry it into the letter even when the surrounding sentence is otherwise condensed. In particular, when they were stated in the source material: - Include every vital sign and every physical exam finding the clinician reported, including normal findings -- but only for systems that were actually examined; never add an exam finding or system that was not reported. - Include symptoms the patient denied or that were specifically asked about and found absent. - Include medications and supplements started, stopped, changed or continued, with dose, frequency and reason. - Include relevant past history and triggers the patient mentioned, and the patient's own concerns, questions and goals of care, with what they were told. - In Assessment & Plan, give each distinct problem its own numbered item -- including active problems carried in the prior notes or intake (e.g., heart failure, coronary disease) that were addressed or have a plan, not only the main reason for the visit. Under each, list every action as specifically as it was stated: tests ordered and why, treatments with doses, conditional plans ("if the result is positive, then ..."), options the clinician suggested considering, referrals, follow-up timing and method, and return/escalation advice (when to seek urgent care, what to avoid, for how long). Do not replace a stated recommendation with a vaguer one such as "discuss with primary physician." In Patient Identification, write "admitted for" only for inpatients; for clinic, telephone or virtual visits write "seen for". Only include a finding, pertinent negative, diagnosis, dose, date, or instruction that was actually stated -- never infer or invent one.

Template

Patient Identification: [Patient name, age, gender, with a history of..., admitted for...] Interval history: (Update of the patient since the last encounter in paragraph form. Use full sentences and formal clinical language. State facts plainly. If mentioned, review of systems should be the last paragraph.) Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [Physical exam findings and/or mental status exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant) Investigations: (hyphenated list) - [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan) Assessment & Plan: (Do not fabricate the assessment and plan unless mentioned in the source material. Use medical terminology if appropriate) #) [List the assessment as a numbered item] - [Hyphenated list with corresponding items underneath]