A progress note documents a patient's status at a follow-up visit and tracks what has changed since the last one. Unlike an initial evaluation, it assumes a baseline already exists, so it is usually shorter and focused on change: symptoms, function, response to treatment, and the plan going forward.
What Every Progress Note Needs, Regardless of Format
| Section | What it captures |
|---|---|
| Status since last visit | What has changed: symptoms, function, and adherence to the prior plan |
| Findings | What you observed or measured today |
| Assessment | Your read on progress toward the treatment goal |
| Plan | Adjustments to treatment and timing of the next visit |
Blank Progress Note Template
This version works across settings. Copy it into a notes app or an EHR free-text field, or download and print it.
Download blank template (PDF)Free, no signup required.
Example of a Completed Progress Note
A primary care follow-up for type 2 diabetes. This is illustrative. It does not describe a real patient and contains no protected health information.
- Status since last visit. Patient reports checking blood glucose most mornings, with readings between 110 and 140. No hypoglycemic episodes. Following the dietary changes discussed last visit about half the time.
- Findings. A1C 7.1 percent, down from 7.8 percent three months ago. Weight down 4 pounds. Foot exam unremarkable.
- Assessment. Improving glycemic control on the current metformin dose and partial dietary adherence.
- Plan. Continue the current metformin dose. Reinforce dietary changes and refer to nutrition counseling. Recheck A1C in 3 months.
Progress Notes by Setting
- Therapy and mental health. Often written in DAP or BIRP to capture what was done in session and how the client responded. See DAP notes and BIRP notes.
- Nursing. Centers on vital signs, interventions performed during a shift, and patient response.
- Primary care and specialty medicine. Usually written in SOAP, since a physical exam or measurement is part of most visits.
Not sure which format fits your practice? See DAP vs BIRP vs SOAP.
See How ClinicFrame Writes Your Progress Notes
ClinicFrame is an ambient AI scribe that transcribes a visit and drafts the note in SOAP, DAP, BIRP, or a custom template, so most progress notes do not have to be filled in by hand. You review the draft and sign off before it becomes part of the record.
