Progress Note Template: Inpatient & Outpatient Structure, SOAP vs. APSO, Worked Example, and LOINC 11506-3

A progress note template is the standardized clinical documentation structure that physicians, advanced practice providers, nurses, and rehabilitation therapists use to record a patient’s interval clinical course, response to treatment, updated diagnostic assessment, and ongoing management plan during an inpatient hospital stay or longitudinal outpatient follow-up. Governed in hospital acute care by the CMS Conditions of Participation at 42 CFR § 482.24(c)(4)(vii) and exchanged across Electronic Health Records (EHRs) under USCDI Clinical Notes using LOINC 11506-3 (Progress note), a well-designed progress note template supports interprofessional care continuity, clinical documentation improvement (CDI), and clinical trial adverse-event tracking.

What Should Be Included in a Progress Note Template? (Core Sections & CMS Rules)

Unlike an initial Admission History and Physical (H&P) or comprehensive patient intake form, a progress note documents what has changed since the previous encounter (interval evolution) and why current therapies are being continued, modified, or discontinued.

Under 42 CFR § 482.24(c), Joint Commission Record of Care (RC) standards, and the CMS 2021/2023 Evaluation and Management (E/M) guidelines (covering subsequent inpatient hospital care CPT 99231–99233 and established outpatient visits CPT 99212–99215), a compliant progress note template includes seven essential components:

1. Encounter Metadata & Authentication Header: Patient full name, medical record number (MRN), date of birth, encounter date and exact time, hospital day / post-operative day (if inpatient), author name and credentials, and billing modality (Medical Decision Making [MDM] vs. Total Time on the date of encounter).
2. Interval History / Subjective Events (24-Hour Events): Overnight or interval clinical events, nursing reports, acute symptoms (pain, dyspnea, nausea, fever), treatment tolerance, and patient-reported functional status since the prior note.
3. Objective Data (Vitals, I&Os, Targeted Physical Exam, and New Results):
   • 24-Hour Vital Sign Ranges & Current Vitals: Temperature (T_max and current), heart rate range, blood pressure range, respiratory rate, SpO₂ and oxygen delivery device/flow rate.
   • 24-Hour Intake and Output (I&O) & Daily Weight: Fluid balance (mL net) and daily weight trend (critical in heart failure, nephrology, and ICU progress notes).
   • Medically Appropriate Physical Examination: Focused organ-system exam aligned with the active clinical problems (following a structured physical exam template).
   • Interval Laboratory, Microbiology, and Diagnostic Imaging Interpretation: Independent interpretation or review of new labs, cultures, ECGs, or radiographs—avoiding uncurated copy-paste “note bloat” of historical lab tables.
4. Problem-Oriented Assessment and Plan (By Active Diagnosis): A numbered or prioritized list of active acute and chronic conditions, stating each condition’s current acuity/stability (e.g., resolving, stable, worsening), diagnostic reasoning, and specific medication, diagnostic, or procedural orders.
5. Inpatient Prophylaxis, Lines/Tubes/Drains, and Disposition Bundle (Hospital Progress Notes): Venous thromboembolism (VTE) prophylaxis status, stress ulcer prophylaxis, invasive catheter/central line day count and necessity (CLABSI/CAUTI prevention), code status / advance directive verification, and anticipated discharge criteria.

Reusable Blank Progress Note Template (Problem-Oriented Inpatient / Outpatient Format)

PROGRESS NOTE TEMPLATE (LOINC 11506-3)
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Patient Name: [Last, First]           MRN: [ID]          DOB: [YYYY-MM-DD]
Date of Service: [YYYY-MM-DD]         Time: [HH:MM]      Location: [Unit / Clinic]
Hospital Day (HD): [#] / Post-Op Day (POD): [# or N/A]
Author: [Name, Credentials]           Supervising Physician: [If applicable]

1. INTERVAL HISTORY / SUBJECTIVE (Overnight / Interval Events)
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- Chief Interval Concern / Overnight Events: [Events since last note]
- Patient-Reported Symptoms: [Pain scale, sleep, appetite, mobility, bowel/bladder]
- Treatment / Medication Adherence & Tolerance: [Side effects or barriers]

2. OBJECTIVE DATA
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- Vitals (24h Range / Current): Tcurrent [°C] (Tmax [°C]) | HR [min-max] | BP [min-max] | RR [rate] | SpO2 [%] on [RA / O2 L/min]
- 24h Intake / Output & Weight: In [mL] | Out [mL] (Urine: [mL]) | Net: [+/- mL] | Weight: [kg] (Δ [kg])
- Targeted Physical Exam:
  * General: [Appearance, distress level]
  * Cardiovascular: [Rhythm, murmurs, peripheral edema]
  * Pulmonary: [Effort, breath sounds]
  * Abdomen: [Bowel sounds, tenderness, distension]
  * Neurological / Extremities /Lines: [Alertness, focal deficits, IV/catheter sites]
- Interval Labs & Microbiology Reviewed: [Pertinent new abnormal/trending values]
- Interval Imaging / Diagnostics Independently Reviewed: [Modality, date, clinical finding]

3. ASSESSMENT & PLAN (Problem-Oriented Medical Record)
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Problem #1: [Primary Active Diagnosis — Acuity / Status (Improving, Stable, Worsening)]
  - Assessment / Clinical Reasoning: [Differential, response to therapy, severity]
  - Diagnostic Plan: [Labs, imaging, or monitoring ordered today]
  - Therapeutic Plan: [Medication dose adjustments, procedures, consults]

Problem #2: [Secondary Active / Chronic Condition — Status]
  - Assessment & Plan: [Continuation or adjustment of home regimen]

4. INPATIENT SAFETY & DISPOSITION CHECKLIST (If Hospitalized)
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- Diet / Nutrition: [Regimen]
- VTE Prophylaxis: [Pharmacologic (Agent/Dose) vs. Mechanical vs. Contraindication]
- Lines / Tubes / Drains (Day # & Indication): [PIV / Central Line / Foley removal check]
- Code Status: [Full Code / DNR / DNI — Verified]
- Anticipated Discharge Plan & Barriers: [Target discharge date, home health/SNF needs]

Total Encounter Time (if time-based E/M): [Minutes spent on date of encounter]
Electronically Signed By: [Clinician Name, Credentials] on [YYYY-MM-DD HH:MM]

Worked Progress Note Example (Fictional Illustrative Inpatient Encounter)

The following fictional example illustrates a Hospital Day 2 inpatient medicine progress note structured for both clinical clarity and CMS 42 CFR § 482.24 compliance:

• Encounter Header: Date: 2026-11-09, 08:15 | Hospital Day 2 | Inpatient Telemetry Unit.
• Interval History (Subjective): 68-year-old male admitted yesterday for acute on chronic systolic heart failure exacerbation (NYHA Class III). Reports improved orthopnea overnight after 2.4 L diuresis; slept with 2 pillows (down from 4). Denies chest pain, palpitations, dizziness, or cough.
• Objective:
  • Vitals: T 36.7 °C (T_max 36.9 °C), HR 74–84 bpm (current 76), BP 118/72–134/80 mmHg (current 122/74), RR 16/min, SpO₂ 96% on Room Air (weaned off 2 L/min nasal cannula at 06:00).
  • I&O / Weight: 24h Intake 1,150 mL | Urine Output 2,850 mL | Net −1,700 mL. Weight 84.2 kg (down 1.6 kg from admission weight 85.8 kg; dry weight 81.5 kg).
  • Focused Exam: JVP 9 cm H₂O at 45° (down from 13 cm). Lungs with mild bibasilar crackles at bases only (improved from mid-lung fields). Heart regular rhythm, S1/S2 normal, no S3 gallop. 1+ pitting edema bilateral shins (improved from 2+ to knees). Peripheral IV right forearm intact without erythema.
  • Interval Labs: BMP this morning: Na 138 mmol/L, K 3.9 mmol/L (repleted with 40 mEq oral KCl yesterday), BUN 26 mg/dL, Serum Creatinine 1.28 mg/dL (admission baseline 1.25 mg/dL), NT-proBNP 3,420 pg/mL (admission).
• Assessment & Plan:
  1. Acute on chronic systolic (HFrEF, LVEF 30%) heart failure exacerbation — Improving: Triggered by dietary sodium indiscretion; euvolemic target ~2.7 kg away with stable renal function.
     Plan: Continue IV furosemide 40 mg q12h today; strict I&O, daily standing weight, 2 g sodium / 1.5 L fluid restriction. Re-check BMP and magnesium tomorrow morning; transition to oral loop diuretic once within 1 kg of dry weight. Continue home carvedilol 25 mg BID and sacubitril-valsartan 49/51 mg BID.
  2. Hypokalemia secondary to loop diuresis — Resolved (K 3.9 mmol/L): Maintain K ≥ 4.0 mmol/L; give 20 mEq oral KCl x1 today.
  3. Inpatient Prophylaxis & Disposition: Subcutaneous enoxaparin 40 mg daily for VTE prophylaxis; no urinary catheter in place; Full Code; anticipate transition to oral diuretics tomorrow and home discharge with cardiology follow-up in 7 days.

How Is a Progress Note Template Structured in EHR Workflows? (SOAP vs. APSO and HL7 FHIR)

In modern EHRs, clinical informatics committees configure progress note templates around two structural and interoperability standards:

Format / Standard	Section Ordering & Technical Identifier	Clinical & Informatics Rationale
Traditional SOAP Note Layout	Subjective → Objective → Assessment → Plan	Follows chronological data-gathering order; preferred in initial outpatient visits and nursing SOAP notes.
APSO Progress Note Layout	Assessment → Plan → Subjective → Objective	Places the active problem list and clinical plan at the very top of the screen so cross-covering hospitalists, consultants, and clinical trial monitors do not have to scroll past multi-page lab dumps to find the medical decision-making.
HL7 C-CDA R2.1 & FHIR US Core Mapping	LOINC 11506-3 (Progress note); C-CDA templateOID 2.16.840.1.113883.10.20.22.1.9	Exposes every signed inpatient and outpatient progress note via the EHR’s USCDI FHIR DocumentReference API (withspecialty children such as LOINC 28570-0 Procedure note or 18748-4 Diagnostic imaging study).