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Free medical progress note generator
Turn follow-up visit shorthand into a progress note that shows what has changed since last time, what the results say and what you are doing about it.
How to use it
- 01
Paste what changed
Start from the last visit: symptoms since then, side effects, home readings, new results. Shorthand and abbreviations are fine.
- 02
Add today’s findings
Include today’s observations and any blood or imaging results, with the previous value where you have it, so the trend is visible.
- 03
Check the plan
The draft keeps medication changes, monitoring and follow-up intervals exactly as you wrote them. Review it before it goes in the record.
What goes in a progress note?
A progress note documents a follow-up encounter for a problem that is already known. Instead of retelling the whole history, it records what has changed since the last visit and how today’s findings move the plan forward. It is the everyday note for chronic disease reviews, medication checks and post-treatment follow-ups.
- Reason for visit
- Why the patient is being seen today: the condition under review and what triggered the visit, such as a scheduled review or a recent change in treatment.
- Interval history
- What has happened since the last contact: symptoms, side effects, adherence, home measurements and lifestyle changes the patient reports.
- Examination and results
- Today’s observations and examination, plus new test results, ideally next to the previous value so the trend is clear.
- Assessment
- How each problem is doing: improving, stable or worse, and whether it is at target.
- Plan
- Medication changes with dose, monitoring, outstanding decisions, who does what, and when the next review is.
Progress note example: diabetes and blood pressure review
Reason for visit
Scheduled follow-up of type 2 diabetes and hypertension, three months after metformin was increased to 1 g twice daily.
Interval history
Loose stools for the first two weeks after the dose increase, now settled. Home blood pressure readings mostly 135–145/85 mmHg. No chest pain or shortness of breath. Walking 30 minutes most days and reports an improved diet. No numbness in the feet.
Examination and results
BP 142/88 mmHg, repeat 138/86 mmHg. Heart rate 76, regular. Weight 94 kg (previously 97 kg). Feet: pulses present, monofilament sensation normal. HbA1c 58 mmol/mol (previously 71). eGFR 78, potassium 4.4 mmol/L. Total cholesterol 5.2 mmol/L, LDL 3.1 mmol/L.
Assessment
Type 2 diabetes: glycaemic control improving after the metformin increase; gastrointestinal side effects resolved. Hypertension: above target on clinic and home readings.
Plan
Continue metformin 1 g twice daily. Start ramipril 2.5 mg once daily, with U&E in 2 weeks. Nurse blood pressure check in 4 weeks. Repeat HbA1c in 3 months. Statin discussed; the patient would like time to consider it.
Need the diagnosis code too? Search ICD-10-CM codes
Tips for clearer progress notes
- Write results with the previous value in brackets (“HbA1c 58, was 71”) so the trend is obvious without opening old notes.
- Give each problem its own line in the Assessment and say whether it is improving, stable or worse.
- Record every medication change with drug, dose and frequency, and the monitoring it needs (for example kidney function after starting an ACE inhibitor).
- Note decisions the patient has deferred, such as starting a statin, so the next clinician knows to revisit them.
- End with a concrete follow-up: what is checked, by whom and when.
Frequently asked questions
Progress note vs SOAP note: what’s the difference?
A SOAP note can document any encounter, including a first visit. A progress note is for follow-ups: it focuses on what has changed since the last contact and how the plan is moving forward. Many progress notes are written in SOAP order; this format simply makes the interval and the trend explicit.
Can I use it for several problems in one visit?
Yes. Paste everything you covered. The draft keeps each problem separate in the Assessment and Plan, as long as your notes make clear which finding belongs to which problem.
Will it add results or doses I didn’t write?
It is instructed to use only what you pasted and to write “Not documented” where something is missing. Always check doses and values against your source before saving the note.
Is it free?
Yes. You can write up to 10 notes a day without an account.
Is it safe to paste patient information?
Paste clinical details only, never names, ID numbers or contact details. The text is sent to our AI provider to write the note and is not saved by Docdemic.