Chelsea Joy Beleno

BSN 3A

Midterm Requirement 2

Progress Note Reflection

First of all, a progress note documents a patient's medical status which is one of the very
important piece of information we need before we create an assessment. Basically a progress
note has all the information needed to know the patient and should be written in chronological
order. And taking note that this document is considered a legal document that can be used for
court proceedings, insurance reimbursement, etc. Of course ADPIE, also known as
Assessment, Diagnosis, Planning, Implementation, and Evaluation, plays a huge role and
shapes the progress note. A progress note is a narrative description of what happened with the
patient, so we put the patient’s condition, any abnormalities, medication, diagnostic results, etc.
Stated in the video we have 3 types of progress notes and they are SOAP, PIE, and DAR;
taking note the the SOAP note is the most commonly used by nurses.
SOAP note is focused on the reason for seeing the patient, included in the note is the subjective
observation, objective observation, assessment and the plan.
Next is the PIE note. According to the video, this is also a problem oriented note but this relies
more on the use of the nursing diagnosis to identify and document the problem. Included in the
note are the problem, intervention, and evaluation. This note may be straight to the point but it
doesn’t have more detail as SOAP notes do.
Lastly we have DAR notes also known as focus notes. Stated in the video, DAR notes are in a
different category because this note only highlights a specific problem. This note takes note on
what the nurses do and did they adjust the problem we’ve identified and did it work. Included in
the note are the Data, Action and Response
Moving forward to the rule on writing the progress note and what to remember, take not that
progress notes are a legal document so the nurse should be professional in writing the note.
The rules are: Be consistent & concise, Be timely, Use standard abbreviations, Include all
communication, and sign with credentials. And while writing the note always write legibly, use
black ink, and have caution with errors.