Progress Note Template
Progress notes track ongoing patient management over time. They are essential for chronic disease reviews, follow-up appointments, and multidisciplinary handovers. Use this template or let WhiteFieldHealth generate it from a recording.
WhiteFieldHealth
Built for reviewable clinical documentation, not generic AI output.
When to use a progress note
Progress notes are used for follow-up appointments where the clinical picture is evolving rather than being established for the first time. They are the standard format for chronic disease management reviews (diabetes, COPD, heart failure), post-operative follow-ups, and ward rounds. Unlike an initial consultation note, a progress note focuses on what has changed since the last encounter and whether the current management plan is working. This makes them essential for continuity of care, particularly in shared-care arrangements between primary and secondary care.
Worked example: Diabetes management follow-up
Current Status
62-year-old male with type 2 diabetes mellitus (diagnosed 2018), hypertension, and obesity (BMI 33.1). Currently on metformin 1 g BD, gliclazide 80 mg OD, ramipril 10 mg OD, and atorvastatin 40 mg ON. Last HbA1c 58 mmol/mol (target <53). Last BP 142/88 mmHg. Annual diabetic review due.
Interval History
Since last review 3 months ago: reports improved dietary compliance following dietitian referral. Now walking 20 minutes daily, up from sedentary. Weight stable at 102.4 kg (previously 103.1 kg). No hypoglycaemic episodes. No polyuria or polydipsia. Adherence to medication: takes all tablets regularly, no missed doses. Reports occasional lower limb tingling bilaterally, worse in the evenings. No foot ulceration or colour changes noted. Eyes: attended diabetic retinopathy screening last month — result awaited.
Assessment
HbA1c 54 mmol/mol (improved from 58, now approaching target of <53). BP 136/84 mmHg (improved, now within NICE target <140/90). Weight 102.4 kg, BMI 33.1 (stable). Foot examination: peripheral pulses palpable bilaterally (dorsalis pedis and posterior tibial). Monofilament sensation reduced at 1st and 5th metatarsal heads bilaterally — early peripheral neuropathy. No calluses, ulceration, or deformity. Urine ACR: 4.2 mg/mmol (normal <3, mildly elevated — repeat in 3 months). eGFR 72 mL/min (stable, CKD stage 2). Lipid profile: total cholesterol 4.1, LDL 2.0, HDL 1.3, triglycerides 1.8 — well controlled.
Plan Update
1. Glycaemic control: HbA1c improving but not yet at target. Add empagliflozin 10 mg OD (SGLT2 inhibitor — cardiovascular and renal benefit, weight reduction). Continue metformin 1 g BD and gliclazide 80 mg OD. 2. Neuropathy: commence duloxetine 30 mg OD if tingling progresses — currently watchful waiting. Refer to podiatry for annual review and protective footwear assessment. 3. Renal: repeat urine ACR in 3 months. If persistently elevated >3, consider ACEi optimisation. 4. Retinopathy screening: chase result, ensure filed in notes. 5. Lifestyle: reinforce dietary changes and exercise programme. Consider structured education (DESMOND course) if not previously attended. 6. Sick day rules reinforced with addition of SGLT2 inhibitor — written card provided. 7. Next review: 3 months with repeat HbA1c, U&E, urine ACR. Annual review items (retinopathy, foot check, lipids) completed today.
Tips for effective progress notes
Show the trajectory
Compare current values to previous readings. Trends in HbA1c, BP, or weight tell a clearer story than a single data point.
Measure against targets
Reference NICE or local guidelines targets explicitly. This makes it clear whether the patient is on track or needs escalation.
Document what changed
Highlight any medication changes, dose adjustments, or new referrals. The reader should immediately see what is different from the last visit.
Set a clear review timeline
End with the date or interval for the next review and what investigations should be completed before that appointment.
Cross-reference annual checks
For chronic conditions like diabetes, note which annual review items have been completed and which are outstanding to avoid duplication.
How WhiteFieldHealth generates progress notes automatically
WhiteFieldHealth captures the follow-up consultation, extracts interval changes, updated investigation results, and management decisions, and structures them into a progress note. When previous notes exist in the system, the AI references historical values to highlight trends automatically. Drug changes are cross-referenced with BNF guidance through our AI medical scribe pipeline, ensuring new prescriptions are flagged for interactions or contraindications.
Ideal for chronic disease management in GP practices and shared-care clinics. See pricing for plan details.
Generate progress notes automatically
Record follow-up consultations and get structured progress notes with trend tracking and plan updates in seconds.