{"id":1661,"date":"2026-07-11T02:55:17","date_gmt":"2026-07-11T02:55:17","guid":{"rendered":"https:\/\/itaca.ai\/?page_id=1661"},"modified":"2026-07-11T02:55:18","modified_gmt":"2026-07-11T02:55:18","slug":"hospital-progress","status":"publish","type":"page","link":"https:\/\/itaca.ai\/en\/notas-clinicas-ia\/plantillas\/progreso-hospitalario\/","title":{"rendered":"Hospital Progress Note: Template and Example"},"content":{"rendered":"
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Hospital Progress<\/p>\n\n\n\n

Keep the daily evolution and active issues of the hospitalized patient visible<\/h2>\n\n\n\n

In hospitalization, information accumulates between shifts, studies, and interventions. A clear progress note helps distinguish what changed today, what problems remain active, what decisions were made, and what is still pending.<\/p>\n\n\n\n

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Create my first note<\/a><\/div>\n<\/div>\n<\/div>\n\n\n\n
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\"Clinical<\/figure>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n
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CLINICAL STRUCTURE<\/p>\n\n\n\n

A hospital progress note should include:\n\n* **Date and Time:** When the note was written.\n* **Patient Identification:** Patient's full name and medical record number.\n* **Provider Identification:** The name and title of the healthcare professional writing the note.\n* **Subjective Information (S):**\n * Patient's report of their symptoms, how they are feeling, and any concerns.\n * Patient's response to treatment.\n* **Objective Information (O):**\n * Vital signs (temperature, blood pressure, pulse, respiration rate, oxygen saturation).\n * Physical exam findings.\n * Laboratory results.\n * Imaging results.\n * Results of any diagnostic tests.\n* **Assessment (A):**\n * The healthcare provider's interpretation of the subjective and objective data.\n * A summary of the patient's progress or decline.\n * Diagnosis and any changes in diagnosis.\n* **Plan (P):**\n * What will be done next.\n * Further diagnostic tests.\n * Medication changes or new prescriptions.\n * Consultations with other specialists.\n * Therapies (physical, occupational, etc.).\n * Patient education.\n * Discharge planning (if applicable).<\/h2>\n\n\n\n

The structure should facilitate continuity between professionals without turning daily progress into an extensive copy of already known information.<\/p>\n\n\n\n

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\"Evolution<\/figure>\n\n\n\n

Evolution and objective data<\/h3>\n\n\n\n

Symptoms, changes since last assessment, vital signs, examination, assessment when applicable, and response to management.<\/p>\n<\/div>\n<\/div>\n\n\n\n

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\"Problems<\/figure>\n\n\n\n

Problems and studies<\/h3>\n\n\n\n

Active problems, lab\/imaging results, prognosis, pain, nutrition, and other elements that change decisions.<\/p>\n<\/div>\n<\/div>\n\n\n\n

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\"Plan<\/figure>\n\n\n\n

Plan and pending items<\/h3>\n\n\n\n

Treatment, interconsultations, studies to review, goals for the day, discharge criteria, and pending items for the next shift.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n

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\"Illustrative<\/figure>\n\n\n\n

Hospital progress note<\/h3>\n\n\n\n