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Document Sample
MEDICAL RECORD
PROGRESS NOTES
DATE
(Continue on reverse side)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name - last, first, middle; grade; rank; rate; hospital or medical facility)
REGISTER NO. |
WARD NO. |
|
|
PROGRESS NOTES
Medical Record
STANDARD FORM 509 (REV.
Prescribed by GSA/ICMR, FIRMR (41 CFR)
PROGRESS NOTES
DATE
STANDARD FORM 509 (REV.
Document Information
| Fact Name | Description |
|---|---|
| Form Purpose | The Progress Notes form is designed to document patient care and treatment progress in medical records. |
| Standardization | This form is a standardized document, known as Standard Form 509, which ensures consistency across medical facilities. |
| Governing Regulations | It is prescribed by the General Services Administration (GSA) and is governed by the Federal Information Resources Management Regulations (FIRMR). |
| Revision Date | The current version of the form was revised in July 1991, reflecting updates in medical documentation practices. |
| Patient Identification | It requires comprehensive patient identification details, including name, grade, rank, rate, and facility of care. |
| Record Keeping | Progress notes are crucial for maintaining accurate medical records, which are essential for ongoing patient care. |
| Continuation Option | The form allows for continuation on the reverse side, providing space for additional notes as needed. |
Progress Notes - Usage Guidelines
Filling out the Progress Notes form is a straightforward process that requires attention to detail. This form is essential for documenting patient information and medical observations. Follow these steps carefully to ensure all necessary information is accurately recorded.
- Date: Write the date of the entry at the top of the form.
- Patient's Identification: Fill in the patient's name (last, first, middle), grade, rank, rate, and the name of the hospital or medical facility.
- Register Number: Enter the patient's register number, which is typically assigned by the medical facility.
- Ward Number: Indicate the ward number where the patient is being treated.
- Progress Notes: Document your observations, treatment provided, and any other relevant information regarding the patient's condition.
After completing the form, review it for accuracy. Make sure all sections are filled out correctly before submitting it to the appropriate medical records department.
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Dos and Don'ts
When filling out the Progress Notes form, it is important to follow certain guidelines to ensure accuracy and clarity. Here are five things you should and shouldn't do:
- Do write the date clearly at the top of the form.
- Do include the patient's full name, including last, first, and middle name.
- Do provide the patient's grade, rank, or rate as applicable.
- Don't leave any sections blank; fill in all required information.
- Don't use abbreviations that may not be understood by others.
Common mistakes
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Incomplete Patient Identification: One common mistake is not providing complete patient identification. It’s crucial to include the patient's full name (last, first, middle), grade, rank, rate, and the name of the hospital or medical facility. Omitting any of these details can lead to confusion and miscommunication.
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Neglecting to Date Entries: Failing to date the progress notes can create significant issues in tracking a patient’s history. Each entry should have a clear date to maintain an accurate timeline of the patient's treatment and progress.
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Inconsistent Documentation: Inconsistency in how notes are documented can lead to misunderstandings. It’s important to use the same format and terminology throughout the notes. This helps ensure that anyone reviewing the notes can easily understand the patient’s condition and treatment plan.
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Not Following the Standard Form: Many individuals overlook the importance of using the correct standard form. The Progress Notes should be completed using the designated Standard Form 509. Deviating from this format can result in incomplete records and potential compliance issues.