Progress note template for physicians, with a follow-up example

A progress note documents a follow-up visit: what has changed since the last encounter, how the patient is responding to treatment, today's findings and results, the clinician's assessment and the next steps. This page gives a physician progress note template with Interval History, Current Status, Findings, Assessment and Plan, plus worked follow-up examples.

Transcription and the draft note are usually ready within 1–3 minutes of pressing Stop; the note itself takes about 20–40 seconds.

Last updated Scripta by SyncEdge

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Scripta drafts documentation of what was said in the visit; the clinician reviews, edits and signs; it does not diagnose.

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Progress note vs SOAP note: what's the difference?

SOAP is a format; a progress note is a purpose. A progress note records a follow-up visit and can be written in SOAP order, but it starts from what changed since the last visit. Scripta's progress template makes that explicit with Interval History and Current Status.

Use a SOAP note the first time a patient comes with a problem, and a progress note each time they come back for it.

What should a follow-up visit note include?

Five things: what has happened since the last visit, how the patient is now, today's findings and results, your assessment of progress, and the plan. Each maps to one section of the template.

Interval History
What has happened since the last visit: symptom changes, new problems, events, and how the patient has taken the treatment.
Current Status
How the patient reports feeling now, and their current medicines as stated.
Findings
Vital signs, examination and results stated aloud during this visit only.
Assessment
The clinician's stated assessment of progress and response to treatment.
Plan
Changes to treatment with exact doses, investigations, advice and the next follow-up, as stated.

Progress note example: two weeks after starting treatment

The rice farmer from the SOAP note example came back after two weeks of omeprazole. Scripta drafted this progress note from the follow-up conversation, using the first visit's note, linked by HN, for continuity.

Progress noteFollow-up at 2 weeks · epigastric pain improvingFictional patient for illustration

Interval History

  • Follow-up of burning epigastric pain. Much better; mild burning remains on an empty stomach.
  • No further vomiting; stools normal, not black.
  • Taking omeprazole every morning before breakfast; missed one dose.
  • Stopped the mixed pills and ibuprofen. Takes one paracetamol for back pain when needed; some days none.
  • Stopped alcohol, apart from one drink with friends at a temple festival.
  • Has not yet identified the medicine that caused the rash; daughter will ask the pharmacy.

Current Status

  • Feels much better.
  • Current medications: omeprazole before breakfast, amlodipine one tablet daily, paracetamol as needed for back pain.

Findings

  • BP 128/80 mmHg, pulse 76
  • Mild epigastric tenderness, much less than at the last visit

Assessment

Clearly improved; responding to treatment.

Plan

  • Continue omeprazole 20 mg once daily before breakfast for another 2 weeks, to complete 4 weeks.
  • Continue paracetamol for back pain.
  • Do not go back to the mixed pills or ibuprofen.
  • Continue to avoid alcohol.
  • If pain returns after finishing omeprazole, refer for endoscopy.
  • Patient to report the name of the medicine that caused the rash.
  • Follow-up in 4 weeks.

Please verify (shown to the clinician, not part of the note)

  • The medicine that caused the rash is still unknown; awaiting the pharmacy.
  • Paracetamol and amlodipine doses were not stated at this visit.

How do you write the note when lab results come back?

Start from the previous plan: which tests were ordered and why. Record the results in Findings with values and units as you read them out, give your interpretation in Assessment, and put the new treatment and next check in Plan. Here is one patient twice on one day: blood tests in the morning, results an hour later.

Blood tests in the morning, results an hour later

HN 6601002 · man, 52Fictional patient for illustration

A 52-year-old man comes in tired, thirsty and passing urine often. The doctor orders blood tests, and he comes back the same morning for the results. Both visits were recorded under the same HN.

Linked by HN 6601002

Visit 1 · SOAP note

Morning, before the blood tests

Subjective

Chief complaint: "very tired" for about 2 months; gets tired after a little work.

  • Passing urine often; gets up 3-4 times a night.
  • Dry mouth, thirsty all the time.
  • Lost about 5 kg in 2 months while eating the same as before.
  • Slightly blurred vision when reading.
  • No numbness in the hands or feet; no foot ulcers or slow-healing wounds.
  • Past history: denies chronic illness; takes no regular medicines; no known drug allergies.
  • Family history: father has diabetes, now on insulin.
  • Social: stopped smoking 5 years ago; drinks alcohol occasionally at social events, about once a week.

Objective

  • BP 142/88 mmHg, HR 84/min, temperature 36.8 °C
  • Weight 78 kg, height 170 cm
  • Not pale, no oedema
  • Foot pulses palpable; normal sensation in the feet

Assessment

The doctor suspects diabetes, from frequent urination, thirst and weight loss with a father who has diabetes, but blood tests are needed first. Not yet confirmed.

Plan

  • Labs: FBS (fasting blood sugar), HbA1c, lipid profile, creatinine, urinalysis.
  • Fasting since 22:00 last night, so blood drawn now; results in about 1 hour.
  • After the blood test he may eat normally, but should avoid sweet drinks, soft drinks and desserts for now.
  • Tell the nurse straight away if he has palpitations, sweating or feels faint.
  • Return to the same exam room once today's results are back.

Please verify (shown to the clinician, not part of the note)

  • Diabetes is not yet confirmed; awaiting the blood and urine results.
  • No medicines were prescribed today, pending the results.

Visit 2 · progress note

About an hour later, same day

Interval History

Came back after waiting for this morning's blood tests. Ate a little rice porridge while waiting; still thirsty.

Current Status

Reports feeling fine; still thirsty. Has not started any medicine.

Findings

  • BP today 138/86 mmHg (slightly lower than this morning)
  • FBS 168 mg/dL
  • HbA1c 7.8%
  • LDL 162 mg/dL
  • Creatinine 0.9 mg/dL, normal
  • Urinalysis: glucose 2+, protein negative

Assessment

The doctor diagnosed type 2 diabetes from the raised FBS and HbA1c together with his symptoms, with high LDL cholesterol. Kidney function is normal.

Plan

  • Metformin 500 mg, 1 tablet twice a day after breakfast and dinner; told about early side effects such as bloating, nausea and loose stools.
  • Atorvastatin 20 mg, 1 tablet at bedtime.
  • Diet: less rice and starch, desserts, sweet drinks and very sweet fruit; more vegetables, fish and chicken breast; avoid fried food.
  • Brisk walking 30 minutes a day, at least 5 days a week; aim to lose about 5 kg.
  • Follow-up in 3 months with a repeat HbA1c.

Please verify (shown to the clinician, not part of the note)

  • Drug allergies were not asked at this visit (the earlier note records no known drug allergies).
  • How long to take metformin and atorvastatin was not stated.

What the follow-up read from visit 1

  • The tests ordered in the morning, so the results are read against the plan that asked for them.
  • The working impression of possible diabetes, waiting on those results.
  • "No known drug allergies" from the first visit, which the draft names as not asked again today instead of copying it in as today's answer.

What came only from today's conversation

  • Every result, and today's blood pressure.
  • The diagnosis of type 2 diabetes, in the doctor's words.
  • The prescriptions, the advice and the 3-month follow-up.

That is the rule at work: the earlier note provides continuity, never today's answers. The doctor reviews both flags before signing.

How does Scripta build the follow-up on the previous visit?

By HN. When you type the patient's HN before recording, Scripta finds that patient's most recent earlier visit, switches the note to a progress note, and gives the draft the earlier note, preferring a clinician note (SOAP, H&P or progress) over a referral or patient summary.

  • The earlier note is used only for continuity: what was planned and which results were pending.
  • Today's findings, results and decisions come only from today's conversation, and the draft states what changed.
  • Earlier findings are never presented as today's.
  • Before you start, the recorder shows the last visit's date and plan, so you know what the draft will build on.

How this fits the clinic day: linking visits by HN.

How should I talk during a follow-up so the progress note is useful?

Ask what changed, read results aloud, and say what you are changing. The draft can only record a change that was spoken, and it will not carry an old value forward as today's.

  • Type the HN before you start, so the draft can read the last visit's note.
  • Ask about adherence, missed doses and side effects; they belong in Interval History.
  • Read results with their values and units: "HbA1c seven point eight percent."
  • Say explicitly what you start, stop or change, with the dose.
  • Give the next follow-up and what will be checked then.
  • Patients can speak Thai, Thai mixed with English, or Isan, Northern or Southern Thai: Scripta accepts the speech, writes the note in standard Thai (or English, if you choose), and flags any word it isn't sure of for you to check.

Copy the progress note template

The five headings Scripta uses for follow-ups, with prompts. It works for outpatient follow-ups and, with a date line per day, for inpatient progress notes.

Plain text, ready to paste into your HIS or EMR
Interval History
Since the last visit on (date):
Symptoms better, worse or new:
How the treatment was taken; missed doses; side effects:
Events since then (admissions, emergency visits):

Current Status
How the patient feels today:
Current medicines, as stated:

Findings
Vital signs today:
Examination today:
Results reviewed today (with the date of each test):

Assessment
Progress and response to treatment, in the clinician's words:

Plan
Changes to treatment (name, dose, frequency, duration):
Investigations:
Advice:
Next follow-up, and what will be checked:

Frequently asked questions

What does F/U mean in medicine?

F/U is short for follow-up: a planned return visit to check how a problem is progressing, review test results or adjust treatment. In Thai outpatient clinics you will often see "OPD F/U" with a date in the plan. The note written at that return visit is the progress note.

How often are progress notes written?

In hospital, usually at least once a day for each inpatient, and more often when the patient's condition changes. In outpatient care, once per follow-up visit. Either way the note answers the same question, what has changed since the last one, and records today's findings and plan.

Can an AI scribe use my previous note when writing the follow-up?

Scripta can, when both visits are linked to the same patient label, such as an HN. The draft reads the earlier visit's note for continuity only, meaning what was planned and which results were pending. Today's findings and decisions come only from today's conversation.

What if the patient had no earlier visit in Scripta?

The progress note is then drafted from today's conversation alone, because there is no earlier note to read. Ask what happened since the last visit and what treatment the patient has had, and say it aloud: it goes into Interval History. Link the visit to an HN so the next follow-up can build on this one.

Should lab values go in Findings or in Assessment?

Results belong in Findings, each with its value and unit as you read it out, such as "FBS 168 mg/dL". Your interpretation, such as "HbA1c above target" or a new diagnosis of type 2 diabetes, belongs in Assessment, and what you do about it belongs in Plan.

How is a nursing progress note different?

Nursing notes often use focus charting, such as DAR (data, action, response), and track care given across a shift. A physician's progress note centres on the clinical assessment and the plan. Scripta's progress template is written for the physician's note.

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