Every time the patient is examined, a careful progress note must be made in the patient record or on the Road-to-Health Card. Continue using the SOAP system. Each item on the problem list must be considered in turn. The history, clinical findings, any special investigations, and plan of action must be recorded for each problem. Only record what is important. One of the greatest mistakes made in writing continuation (follow-up) notes is that they are too long and detailed. Notes must be kept short and simple. No one will read pages and pages of unnecessary writing.
Progress notes should be short and simple and address each unresolved problem.
Once a problem on the list is solved, that problem can be dropped and need no longer be included in the problem list. Any new problem should be added to the list.
In this way, each active problem (i.e. still on the list) should be considered at each examination. This provides a simple, clear and systematic record of the patient’s clinical progress. Any other nurse or doctor can quickly understand the patient’s problems and progress by reading good notes.
The following is a typical example of progress notes using a problem list and SOAP method:
S: Itching is much better, especially at night.
O: Rash improving. No secondary infection.
A: Scabies has responded to treatment with Ascabiol.
P: Give mother Ascabiol to treat whole family.
2. Iron deficiency anaemia:
S: More energy. Good appetite.
O: No longer pale.
A: Good response.
P: Check Hb.
Continue oral iron for 3 months.