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MONTANA STATE HOSPITAL POLICY AND PROCEDURE DOCUMENTATION IN PROGRESS NOTES Effective Date: May 6, 2015, Policy #: HI05 Page 1 of 4 I. PURPOSE: To provide guidelines for the entry of progress notes
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What is documentation in progress notes?
Documentation in progress notes refers to the written record of ongoing observations, assessments, and interventions made by healthcare professionals regarding a patient's care.
Who is required to file documentation in progress notes?
Healthcare professionals such as nurses, physicians, and therapists are required to file documentation in progress notes as part of their duty to maintain accurate records of patient care.
How to fill out documentation in progress notes?
Documentation in progress notes should be filled out with clear, concise, and objective information about the patient's condition, treatment plan, and any changes or updates in their care.
What is the purpose of documentation in progress notes?
The purpose of documentation in progress notes is to track the patient's progress, communicate with other healthcare providers, ensure continuity of care, and serve as a legal record of the care provided.
What information must be reported on documentation in progress notes?
Information such as vital signs, medications administered, procedures performed, patient responses, and any significant changes in the patient's condition must be reported on documentation in progress notes.
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