Hospital progress note template, with a day-two example
Used by: Hospitalists, residents and inpatient consultants, once a day per patient.
The daily progress note answers three questions for whoever reads it next: what changed overnight, where each problem stands, and what the plan is today. Problem-based SOAP is the clearest way to write it.
The template, section by section
Interval events and subjective
Overnight events and how the patient feels today.
- Overnight events
- Symptoms today
- New concerns
Objective
Vitals with trends, intake and output, exam, and new results.
- Vital signs and trends
- Intake, output and weight
- Focused exam
- New labs and imaging
Assessment and plan by problem
For each active problem: status since yesterday and today’s plan.
- Problem, status, plan
- Prophylaxis
- Code status
- Disposition and barriers to discharge
Hospital progress note example
A synthetic example written for an invented patient. It is not a real patient record or medical advice.
Interval events
No events overnight. Net negative 1.8 L. Weight down 1.2 kg.
Subjective
Breathing better, slept flat on one pillow. No chest pain.
Objective
T 36.6, BP 128/76, HR 80, RR 18, SpO2 94% on room air. JVP 8 cm. Fewer bibasilar crackles. 1+ edema at the ankles.
Labs: Na 136, K 3.8, creatinine 1.4 (from 1.5).
Assessment and plan
1. Acute on chronic HFrEF, improving: continue furosemide 40 mg IV twice daily today, plan transition to oral tomorrow if diuresis continues. Daily weights, BMP in the morning. Oxygen weaned off.
2. AKI on CKD 3a, improving: creatinine 1.4. Continue to trend.
3. Type 2 diabetes: glucose 140-190 on sliding scale. Continue; restart metformin when creatinine is back to baseline.
VTE prophylaxis: enoxaparin. Code status: Full Code.
Disposition: anticipate discharge in 1-2 days once on an oral diuretic with stable renal function and the refill plan confirmed.
Tips from practice
- Open with what changed; the reader already has the H&P.
- Give every problem a status word (improving, stable, worsening, resolved).
- Name the barrier to discharge so case management can work on it today.
Let the note write itself in this format
Scribeable writes the note from the visit in the template you choose and suggests the codes, and each sentence drawn from the visit links back to where it came from. You review and sign.
14-day Pro trial, no credit card required. Everything in Pro, including Rounding, for up to 150 notes. To keep Pro after day 14, subscribe for $79/month plus applicable tax. If you don't, nothing is charged and your account becomes read-only, with every note kept.
Questions
- How long should a daily progress note be?
- As long as the active problems need. Carrying forward unchanged text from yesterday makes the note longer without making it more useful.
- Can an AI scribe write notes on rounds?
- Yes. Scribeable’s Rounding Mode records once across many patients and writes one note for each.
Reviewed 2026-11-08.