A detailed, current medical record can be an invaluable asset for patient evaluation. The patient's “old” medical records should be thoroughly reviewed at the time of admission to develop a “framework” for the current medical history and history of present illness （HPI）. Often this information is vital in understanding the patient's immediate condition.
  A periodic review of the initial history and physical exam　record is useful to remind the team members as well as to orient　new team members concerning the patient's current problems. Often it's helpful to review the patient's “active” problem list each day when making rounds.　
When recording the history and physical, the physician should follow several rules:
1. Record all pertinent data.
2. Avoid extraneous data.
3. Use common terms.
4. Avoid nonstandard abbreviations.
5. Be objective.
6. Use diagrams or pictures when indicated.
  All too often a review of the nurses' notes is neglected. Such information allows the clinician to follow patient progress during the previous 24 hrs. period. Particular note should be made of the vital signs; blood pressure, pulse, body temperature and respirations.　
Also fluid intake and urine output is often recorded and should be noted and reported on rounds. As the team evaluates the patient each day on rounds, detailed patient information will promote a more rational approach to patient care. If the nurse records an unusually high or low BP or pulse, this should be re - checked by the physician.　
Other important information sought from the nurses notes include any recorded incidents during the last 24 hrs, such as record of pain episodes, GI distress such as vomiting or diarrhea, febrile episodes or episodes of confusion. Since the nurse spends much more time at the patient's bedside than the physician, her monitoring and report of the patient's condition is extremely valuable and should never be overlooked. The nurse must be respected and treated with courtesy, as she is an integral member of the health care team who can often provide valuable information and provide invaluable assistance in care of the patient.　
In each patient's medical chart, a “Problem List” should be recorded. This lists each problem separately for example, （1） Pneumonia, （2） CHF, （3） Hypertension. A progress note should be written for each “active” problem.
  Detailed daily progress notes recorded in the patient's medical record are valuable for patient assessment. Such a record is helpful for consultants, attending physicians and nurses as it enables them to ascertain the patient's progress. When writing progress notes, it's helpful to follow the SOAP format.　
S = subjective -- This section usually includes a description of patient complaints and symptoms. These should be recorded in the patient's own words.
  O = objective -- This section records pertinent patient physical exam findings including vital signs as well as pertinent recent x- ray, lab and biopsy data. Avoid the notation “vital signs – stable”. A blood pressure of 100/60 in a patient with a history of hypertension may represent relative “hypotension” with significant hemodynamic consequences.　
A-- assessment --This section is often the most neglected in the progress note. However, it is perhaps the most important as decisions regarding selection of diagnostic test and treatment plans are based upon the assessment. A differential diagnosis should be included in this section for problems that have not been clearly elucidated.
  P =plan--In this section is recorded the treatment plan including estimated length of treatment, and discharge plans.　

Following is a sample progress note for a pneumonia patient:
S. Patient c/o cough productive of blood - streaked sputum. He denies any dyspnea.
O: Maximum temp. 38. 5, BP 90/60 R 24, pulse 100, 02 sat 91%
Lung auscultation – rt. mid-lung crackles posterior
Chest X-ray -- resolving rt. middle lobe infiltrate
Sputum and blood cultures -- pending　
A:
1.RML pneumonia -- suspect possible bronchial obstruction from tumor
2.COPD
3.Nicotine dependence
P:
1.Continue antibiotics -- Azithromycin and Ceftriaxone
2.Bronchoscopy tomorrow
3.Nicotine patch　
There should be a separate SOAP progress note for each “active” problem. An “active” problem is one that requires treatment during the current hospitalization. For example a patient may be admitted with CHF and GI bleeding. Each day both problems should be evaluated at the bedside reviewing the history, physical findings and recent lab data. These data should all be recorded in two separate progress notes addressing each specific problem.　
Progress notes must be current; not only should their date be recorded, but ideally the time of day recorded. Occasionally with critically ill patients, it will be necessary to record several progress notes during the same day. Recently, a medical student informed me that she observed a group of medical students busily writing progress notes in charts of patients that had been previously discharged two weeks prior. Such practice is not only useless, but may be “legally” challenged in court. It is the attending physician's responsibility to ensure that his junior staff record progress notes daily. The attending physician should review these notes regularly to ensure compliance.