Hospital Medicine · Templates

Hospital progress note template

A systems-oriented inpatient progress note you can standardize across a hospitalist group, then customize per service line in Wavo.

Template content

Copy or download, then paste into Wavo under My Templates.

Hospital Progress Note

Hospital Day
- Hospital day number and level of care (floor, telemetry, stepdown, ICU step-down as applicable).

Interval Events
- Overnight events, new symptoms, rapid responses, falls, and response to interventions.
- Consultant recommendations and care-coordination updates.

Subjective
- Patient-reported status today: pain, dyspnea, appetite, sleep, mobility, and concerns.

Objective
- Vital signs trends, I/O, oxygen requirement, drains/lines, weight if relevant.
- Focused exam findings.
- Key labs/imaging/microbiology reviewed today with interpretation.

Assessment & Plan
- Problem-based (preferred) or systems-based list with status and next steps for each active problem.
- Code status / goals of care updates if discussed.
- VTE prophylaxis, lines/catters status, glycemic control, and other hospital safety items as relevant.
- Disposition planning, barriers to discharge, and pending items with owners.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Supports problem-based or systems-based planning.
  • Captures overnight events and pending items clearly.
  • Useful organization template for documentation consistency.
  • Keeps disposition planning visible throughout the stay.
  • 1Hospital medicine daily notes
  • 2Inpatient teaching services
  • 3Cross-coverage handoffs

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Hospital Day
Hospital day 3; telemetry floor.

Interval Events
Overnight: one episode of nausea after dinner, improved with ondansetron. No chest pain or desaturations. Cardiology agrees with continuing heparin drip pending coronary CTA tomorrow AM.

Subjective
Feels better; pain 2/10 at IV site only. Ambulating with nursing. Asking about discharge timing.

Objective
Afebrile; BP 118–132/70–78; HR 70s; SpO2 97% RA. Lungs clear; abdomen soft; no edema. Troponin negative ×3. WBC trending down. CTA coronary pending.

Assessment & Plan
1) Chest pain / rule-out ACS — low-intermediate risk; continue ASA, statin, heparin drip; CTA AM; serial exams.
2) Hypertension — restart home amlodipine today; hold ACEi while on aggressive diuresis (not applicable—euvolemic).
3) Disposition — likely discharge tomorrow if CTA non-obstructive and symptoms resolved; follow-up with PCP and cardiology arranged tentatively.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.