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Dictate today's rounds. The progress note comes back in its sections.

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Verbato writes a progress note from your dictation.

For physicians who follow patients day by day.

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Looking for the therapy progress note?

What is a progress note?

A progress note is the physician's note on how a patient in their care is doing since the last one: what changed, the vital signs and examination, new results, the assessment of each problem and the plan.

In practice

A progress note should say what has changed since the last one, and duplicated text makes that hard to find. In more than 104 million notes at one US health system, 50.1% of the text had been duplicated from earlier notes about the same patient; the authors write that duplicate text casts doubt on the veracity of all information in the record (Steinkamp et al., 2022). The Joint Commission warns that copy and paste can promote note bloat, internal inconsistencies and error propagation, and reports expert agreement that information not read and edited should never be copied (Joint Commission, 2021).

Further reading: The Royal College of Radiologists' standards for reporting imaging; Weed (1968), on the problem-oriented record the SOAP note comes from

What you say, and the progress note you get back

Illustrative example

The transcript excerpt and the document are written to show the format. Every name, figure and quote is invented.

What you say · transcript excerpt

vital signs colon temperature thirty seven point eight comma heart rate one ten comma blood pressure one hundred over sixty on norepinephrine twelve micrograms per minute scratch that norepinephrine eight micrograms per minute period new line ventilator on assist control with fio2 forty percent and peep eight period new line urine output nine hundred milliliters in twenty four hours period

  • appears in this excerpt
  • no mark: from a part of the recording not shown here

What comes back · progress note

Date and time

October 26, 07:00.

Interval history

No new events overnight. Sedated, unable to report symptoms.

Vital signs

Temperature 37.8, heart rate 110, blood pressure 100/60 on norepinephrine 8 mcg/min. (appears in this excerpt)

Ventilator on assist control, FiO2 40%, PEEP 8. (appears in this excerpt)

Urine output 900 mL in 24 hours. (appears in this excerpt)

Results

Lactate 2.1, down from 3.4. White count 14.5. Creatinine 1.6.

Assessment

Septic shock from right lower lobe pneumonia, improving.

Acute kidney injury, stable.

Plan and orders

Continue piperacillin-tazobactam 4.5 g IV every 6 hours.

Wean norepinephrine to keep mean arterial pressure above 65.

Spontaneous breathing trial in the morning.

Physical examination · Prognosis — also part of a progress note; nothing in this example's recording calls for it, so it is left out.

Illustrative example

End of the illustrative example. Neither the excerpt nor the document was produced by Verbato.

What it looks like

Verbato's project screen: the progress note, in its sections, with the transcript folded beside it and a box to ask for a change.
  1. The transcript, folded beside the document: one press opens it, line by line with times.
  2. The document, in its sections.
  3. A change, asked for in your own words.

Verbato's app. The content was written to show it.

A blank progress note to copy

Date and time

The date and hour of the note.

Interval history

What changed since the last note, as the patient reported it.

Vital signs

The vital signs, fluid balance and any support, such as oxygen or a ventilator.

Physical examination

The examination, region by region.

Results

The results since the last note, with their trend.

Assessment

Each problem with its certainty and status.

Plan and orders

Treatment and orders, each medication with its dose, route and frequency.

Prognosis

The physician's prognosis.

How your progress note is written

  • A section you did not dictate is left out, never filled with a normal finding.

  • Each problem keeps the status you gave it: improving, stable or worse.

  • Drips, ventilator settings and doses are written as digits, as you dictated them.

  • The word-for-word transcript sits beside the note, so you check before you sign.

Your format, not ours

The sections of your progress note and the way it is written are yours to change. To fix a document, say what is wrong in your own words.

  1. 1You correct it

    “Call the ‘Interval history’ section ‘Subjective’.”

    That progress note changes. Nothing else does.

  2. 2You say it again

    Make the same correction on a later progress note and Verbato asks: “You've changed this before. Always?”

  3. 3You decide

    Answer “Always” and it is kept as a rule, applied from your next progress note on. Answer “Just this once” and nothing is kept. Documents already written stay as they are, and nothing becomes a rule unless you confirm it.

  4. 4Your rules

    I call the “Interval history” section “Subjective”.Undo

    Every rule you have kept is listed, and you can undo any of them. An undone rule stops applying from your next progress note.

How it works

Upload a file, paste a link, record in your browser, or send a voice note by Telegram or email. Verbato makes a word-for-word transcript, which you can edit and which stays beside the document. Your progress note is written from it, in minutes.

Recording limits

A recording made in your browser can run up to 30 min on every plan; a longer session goes in as a file you upload. A free account takes recordings of up to 40 min each; for longer ones, see pricing.

Your recording

Deleted after 7 days by default, together with its transcript and documents. You can keep a project longer, up to your plan's limit. Deleting a recording leaves a receipt you can download. Nothing you record is used to train or improve AI models. Recording patients or clients? Read what Verbato does with sensitive recordings.

Questions about the progress note

Is a progress note always written in SOAP format?
Often, not always. The progress note follows the same idea, what the patient reports, what you found, your assessment and the plan, under headings for the interval history, vital signs, examination, results, assessment and plan.
How is it different from a consultation note?
A consultation note records one visit with a patient. A progress note follows a patient already in your care, often every day in the hospital, so it says what changed since the last note.
Can I dictate the sections in a different order?
Yes. Say a section's name and carry on: what follows goes into that section, whatever order you dictate in. Within a section, the items keep the order you gave them.
What if I correct a dose in the middle of a sentence?
When you dictate to Verbato, say “scratch that” or “correction” and carry on. The note takes the corrected dose and leaves out the slip. The transcript still shows everything you said.
How do I get the note into the hospital's record?
Copy the progress note, or export it as a Word document, a PDF or plain text, and paste it where you sign. Verbato has no built-in connection to your hospital's record system.

The guide

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