A progress note is a dated clinical entry that documents a patient's status, the clinician's assessment, and the plan of care during an ongoing course of treatment. It is typically written at a follow-up visit rather than a first encounter, and it answers three questions: what has changed since the last visit, what the clinician thinks is happening now, and what happens next.
Progress notes appear in every care setting, from primary care and specialty clinics to inpatient units and behavioral health practices. They support continuity of care for the next clinician who opens the chart, provide medical-legal documentation of clinical reasoning, and back up coding and billing. Because progress notes are written far more often than any other note type, their format and quality have an outsized effect on daily documentation time, a burden that time-motion research on physician EHR and desk work has documented in detail (Sinsky et al., 2016).
A progress note documents an established patient's ongoing care, a history and physical documents a new patient encounter or admission, and a consult note documents a specialist's response to a referral question. All three appear in the same chart, but each answers a different question at a different point in the care timeline.
A history and physical (H&P) is comprehensive by design. It captures the full history of present illness, past medical and surgical history, medications, allergies, family and social history, a complete review of systems, and a full physical exam. It is written once, at admission or a new patient visit, to establish a baseline for everything that follows.
A consult note is written by a specialist who was asked to evaluate a specific problem. It typically opens with the reason for consultation, addresses that question directly, and closes with recommendations back to the referring clinician. It does not need to repeat a full H&P if one already exists in the chart.
A progress note, by contrast, is brief and iterative. It assumes the reader already has the H&P or a prior note for context and focuses only on what is new: interval history, updated findings, and any change to the assessment and plan. Most patients accumulate many progress notes between a single H&P and eventual discharge or transfer of care.
Most progress notes follow one of a small number of standardized formats. The format a practice uses often depends on specialty and documentation culture, but the shared goal is the same: organize the note so any reader can find status, reasoning, and plan quickly.
SOAP is the most widely used progress note format, organizing the note into Subjective, Objective, Assessment, and Plan sections. It is the default in most outpatient and inpatient medical settings. For a full breakdown of each section, see the guide to SOAP notes, and for a ready-to-use structure, see the SOAP note template.
DAP condenses the same information into Data, Assessment, and Plan, merging subjective and objective findings into a single Data section. It is common in behavioral health and counseling settings, where the subjective and objective split feels less natural. Read more in the guide to DAP notes.
BIRP stands for Behavior, Intervention, Response, and Plan, and it is built around what happened during a therapy session: the presenting behavior, what the clinician did, how the patient responded, and what comes next. It is common in mental health and substance use treatment documentation. See the full breakdown of BIRP notes.
A narrative progress note tells the visit as a short paragraph or timeline rather than using labeled sections. It can work for brief, low-complexity encounters, but it is harder to scan quickly and easier to write vaguely, which is part of why structured formats like SOAP have become the default in most settings.
Choosing a format is largely a matter of specialty convention, not right or wrong. What matters more than the label is whether the note is scannable, specific, and complete enough that another clinician can pick up the case from it.
Regardless of format, a strong progress note follows a consistent structure. Here is how to build one, using SOAP as the reference structure since it maps cleanly onto the other formats.
The single habit that separates a fast, useful progress note from a slow, unreadable one is specificity: naming the exact medication, dose, symptom, or follow-up date rather than a vague summary.
The example below is intentionally brief, generic, and fictional. It illustrates format only, not clinical guidance, and should not be used as a template for an actual patient without adapting it to the real encounter and the clinician's own judgment.
Subjective: Patient reports feeling about the same since the last visit two weeks ago. Denies new chest pain, shortness of breath, or dizziness. Reports taking medication as prescribed with no missed doses.
Objective: Blood pressure 128/82, heart rate 76, weight stable compared to last visit. Lungs clear, no peripheral edema.
Assessment: Hypertension, stable and at goal on current regimen.
Plan: Continue current medication at current dose. Recheck blood pressure at next visit in three months. Patient advised to continue home monitoring and report readings above 150/95.
Notice what makes this usable: every line is specific, an actual number, an actual timeframe, an actual instruction, rather than a general statement like patient doing well, continue as before.
A few recurring problems account for most weak progress notes.
An AI medical scribe such as DocuMed AI listens to the visit, structures the relevant history, exam, and plan discussion into a progress note draft, and hands that draft to the clinician for review before it goes anywhere else. The clinician still makes every clinical decision. The AI's role is limited to producing the first draft in the correct format.
The workflow is straightforward: the clinician presses record on a mobile device, tablet, or computer with a microphone and proceeds with the visit as usual. Audio is encrypted immediately upon capture and processed on HIPAA-compliant servers by a custom AI transcription model. Progress notes are one of DocuMed AI's named output types, alongside consult notes, H&Ps, discharge summaries, and others, and note templates can be customized to a clinician's preferred structure, including a SOAP-style format. For a broader look at how a scribe builds a structured note from a conversation, see the guide to the AI SOAP note generator.
Because DocuMed AI has no direct EHR integration, the finished note is not pushed automatically into the chart. Instead, the clinician copies the finished note with one click, in full or by section, and pastes it into whatever EHR the practice already uses. That EHR-agnostic design means it works with any EHR system without an IT project or downtime, and it keeps the physician-in-the-loop review step in place before any note becomes part of the record.
For practices weighing documentation time against note quality, cutting drafting time is often the biggest lever. DocuMed AI is reported to reduce daily documentation time by about 50%, roughly 1-2 hours saved per day, time that would otherwise go into typing or dictating first drafts of exactly the kind of structured note described above. To see the full workflow from recording to finished note, visit How It Works.
A progress note should include interval history since the last visit, relevant objective findings, an updated assessment for each active problem, and a specific plan with concrete next steps. Many practices also note the time spent, who was present, and any follow-up interval or referral. The exact section labels depend on the format used, such as SOAP, DAP, or BIRP, but the underlying content is the same across formats.
A progress note should be only as long as needed to support a specific assessment and plan, typically a short paragraph per SOAP section rather than a full page. Length on its own is not a quality signal. A note padded with pulled-forward history or unrelated templated text is not more thorough, it is harder to read and increases the risk that important information gets missed. A concise note with specific details is more useful than a long note with vague ones.
A progress note documents an established patient's ongoing care at a follow-up visit, while a history and physical documents a new patient encounter or admission with a full history and a complete exam. The H&P is written once to establish a baseline, and progress notes are written repeatedly afterward, referencing that baseline rather than repeating it.
Yes, SOAP (Subjective, Objective, Assessment, Plan) is the most widely used progress note format in outpatient and inpatient medicine. It is one of several standardized formats. DAP and BIRP serve a similar purpose in behavioral health and therapy settings, while some practices still use a narrative structure for brief encounters.
No, a progress note documenting a therapy or medical visit is part of the official medical record, while a psychotherapy note capturing a therapist's private process notes is generally kept separate and receives additional privacy protections. See the full comparison of progress notes vs. psychotherapy notes for the practical and legal distinctions.
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DocuMed AI leverages advanced AI Scribe GPT technology to convert ambient sounds and physician-patient conversations into professional medical notes, seamlessly formatted for electronic medical records (EMRs).
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