Progress Notes

• The clinical chart usually starts with some type of initial evaluation.
• What follows is some type of progress note.
• After evaluation the progress note is the meat and potatoes of documentation.
• Important features of the progress notes are as follows:
  • Properly dated and in some cases timed entries.
  • It should have approved abbreviations.
  • It should be legible.
  • The patient's name and id number if any should be there.
  • Objective language should be used.
  • From here forward there is a digression depending on your discipline.

You can document non compliance, any education you give the patient, recommendations, or follow up. You select what you want to put in your progress notes. Use a SOAP format if you like.

• Regardless of how you work in either CRK or CRK-Plus you can have either free text or templates for your progress notes. Simple or complex. Your choice.
  • Although templates sound scary, they are nothing more than a word processing document.
• You can have an outline format.
• Bulleted lists and numbers.
• Headings.
• Boldings, underlinings, and italicizing.
• All the commands are there for fast use.
• Regardless of what discipline you are in, the program comes through for you and helps you every step of the way.
• You don't have to fight separate screens, libraries, or bringing things from elsewhere into the program. It is all in one file you can see and scroll.

• Clinical Record Keeper™and Clinical Record Keeper Plus™ stand ready to help you do your work.
  • Easy to see.
  • Easy to use.
  • Versatile.

To return to the CRK Full Description:  Click Here

To return to the CRK-Plus Full Description:  Click Here

 

Copyright 2007 Charles M. Stewart All rights reserved.