Daily progress note
đź“ť Daily Progress Note (SOAP Format)
Patient Name:
Date:
Post-op Day (if applicable):
Service: (e.g., Neurosurgery)
Responsible physician/team:
🧠S – Subjective Patient report: How the patient feels today, any new complaints (pain, headache, dizziness, nausea, weakness, urinary retention, etc.)
Family concerns: if relevant
Pain control: e.g., “Pain 3/10, well controlled with paracetamol”
🩺 O – Objective Vital signs: T°, HR, BP, RR, SatO₂
Neurological exam: (GCS, pupils, motor/sensory status, cranial nerves if needed)
Wound status: clean, dry, intact; signs of infection
Drains / catheters: output, appearance, if planned for removal
Labs/imaging: pertinent results from bloodwork or radiology
Mobility: out of bed, assistance required, PT/OT notes
💬 A – Assessment Post-op status / diagnosis update: e.g., “POD#2 after L4-L5 decompression. Stable neurologically. No signs of CSF leak or infection.”
Clinical progress: improving, stable, worsening
🗂️ P – Plan Medical management: continue antibiotics, adjust pain meds, taper steroids
Follow-up tests: e.g., repeat CT brain tomorrow, labs daily, plan for MRI
Mobilization / rehab: PT/OT daily, ambulation as tolerated
Disposition: monitor on floor, transfer to rehab, discharge planning
Patient/family communication: updated about recovery and expected plan
âś… Optional Add-ons DVT prophylaxis: on LMWH or SCDs
Nutrition status: tolerating diet, NPO for test, needs nutrition consult
Code status / goals of care: if relevant