Progress Note Writer

Overview

Generate structured daily inpatient progress notes by pulling 24-hour data windows from FHIR resources. Assemble vitals trends, intake and output, laboratory results, imaging results, medication changes, and overnight events into a problem-oriented format. Include standing order status for DVT prophylaxis, GI prophylaxis, diet, activity level, and code status. Flag critical values and significant changes from prior day.

FHIR Resources Used

Instructions

Step 1: Retrieve Encounter and Calculate Hospital Day

Tool: fhir_read
resourceType: "Encounter"
id: "[encounter-id]"

Calculate hospital day: (today - period.start) + 1. Extract admitting diagnosis from reasonCode.

If encounter ID unknown:

Tool: fhir_search
resourceType: "Encounter"
queryParams: "patient=[patient-id]&class=IMP&status=in-progress&_sort=-date&_count=1"

Step 2: Retrieve Patient Demographics

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Step 3: Pull 24-Hour Vital Signs Trends

Define the 24-hour window: [today 00:00] to [now], or [yesterday same-time] to [now].

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=vital-signs&date=ge[24h-ago]&_sort=date&_count=100"

Present as trends:

• Temperature: Tmax, Tcurrent (flag if Tmax >= 38.0 C / 100.4 F)
• Heart rate: Range (low-high), current
• Blood pressure: Range, current (flag if MAP < 65 or SBP > 180)
• Respiratory rate: Range, current
• SpO2: Range, current, oxygen delivery method if available
• Pain score (LOINC 72514-3): Most recent

Step 4: Pull Intake and Output

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=http://loinc.org|9187-6&date=ge[24h-ago]"

LOINC codes for I&O:

• 9187-6: Fluid intake 24h
• 9192-6: Fluid output 24h
• Also search: code=http://loinc.org|9192-6

Calculate net fluid balance. Flag if net positive > 1L or net negative > 2L.

If I&O Observations not available, note: "I&O data not captured in structured FHIR observations -- obtain from nursing flowsheet."

Step 5: Pull Laboratory Results (24h)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&date=ge[24h-ago]&_sort=-date&_count=50"

Group by panel. For each result:

• Compare to prior value if available (trend direction)
• Flag abnormal values with reference range
• Highlight critical values (e.g., K < 3.0 or > 6.0, Na < 125 or > 155, Hgb < 7, platelets < 50k, lactate > 4)

Step 6: Pull Imaging and Diagnostic Reports (24h)

Tool: fhir_search
resourceType: "DiagnosticReport"
queryParams: "patient=[patient-id]&date=ge[24h-ago]&_sort=-date"

Extract conclusion or presentedForm text. If results reference Observation resources in result, follow references with fhir_read.

Step 7: Pull Active Medications and 24h Changes

7a: Current active orders

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&_count=100"

7b: Medications administered in 24h

Tool: fhir_search
resourceType: "MedicationAdministration"
queryParams: "patient=[patient-id]&effective-time=ge[24h-ago]&_count=100"

Identify:

• New medications started in 24h (authoredOn within window)
• Dose changes
• Discontinued medications (status=stopped with authoredOn in window)
• PRN medications administered with frequency

Step 8: Pull Procedures Performed in 24h

Tool: fhir_search
resourceType: "Procedure"
queryParams: "patient=[patient-id]&date=ge[24h-ago]"

Step 9: Pull Active Problem List

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

Step 10: Check Standing Orders and Prophylaxis

Search for prophylaxis orders:

DVT prophylaxis:

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&code=http://www.nlm.nih.gov/research/umls/rxnorm|67108"

RxNorm 67108 = enoxaparin. Also check: 11289 (heparin).

GI prophylaxis:

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&code=http://www.nlm.nih.gov/research/umls/rxnorm|40790"

RxNorm 40790 = pantoprazole. Also check: 29046 (famotidine).

If prophylaxis not found, flag as gap.

Diet and activity: Check CarePlan resources:

Tool: fhir_search
resourceType: "CarePlan"
queryParams: "patient=[patient-id]&status=active&category=http://hl7.org/fhir/us/core/CodeSystem/careplan-category|assess-plan"

Step 11: Assemble Progress Note

DAILY PROGRESS NOTE
====================
Patient: [name] | MRN: [mrn] | DOB: [dob] (Age: [age])
Date: [today] | Hospital Day #[n] | Admitting Dx: [diagnosis]
Service: [service] | Attending: [attending]

OVERNIGHT EVENTS
----------------
[Flag: "Obtain from nursing/overnight team if not in structured data"]
[Include any 24h procedures, code/rapid response events, new consults]

SUBJECTIVE
----------
[Flag: "Obtain from patient interview"]
Pain: [score from LOINC 72514-3 if available]

24-HOUR VITALS
--------------
Tmax: [max temp] | Tcurrent: [current]
HR: [range] ([current]) | BP: [range] ([current])
RR: [range] ([current]) | SpO2: [range]% on [O2 device]

INTAKE & OUTPUT (24h)
---------------------
Intake: [total] mL | Output: [total] mL | Net: [+/-] mL
[Flag if significantly positive or negative]

LABORATORIES
------------
[Panel groupings with trend arrows]
BMP: Na [val][trend] | K [val][trend] | Cr [val][trend] | BUN [val][trend] | Gluc [val][trend]
CBC: WBC [val][trend] | Hgb [val][trend] | Plt [val][trend]
[Additional labs]
[CRITICAL VALUES flagged]

IMAGING / STUDIES
-----------------
[From DiagnosticReport conclusions]

MEDICATIONS
-----------
Active Medications: [count]
New (24h): [list]
Changed (24h): [list]
Discontinued (24h): [list]
PRN Given: [list with frequency]

ASSESSMENT & PLAN (by problem)
------------------------------
1. [Primary problem] - [ICD-10]
   - Status: [improving/stable/worsening based on objective data]
   - Plan: [Flag: "Clinician input required"]

2. [Secondary problem] - [ICD-10]
   - Status: [assessment]
   - Plan: [Flag: "Clinician input required"]

STANDING ORDERS
---------------
DVT Prophylaxis: [medication or "NOT ORDERED - ACTION REQUIRED"]
GI Prophylaxis: [medication or "Not indicated" or "NOT ORDERED - verify"]
Diet: [from CarePlan or "Verify"]
Activity: [from CarePlan or "Verify"]
Code Status: [from Consent or "Verify"]

DISPOSITION
-----------
Estimated discharge: [if available from Encounter.hospitalization]
Barriers to discharge: [Flag: "Clinician input"]

Examples

Example 1: Medical Floor Progress Note

User says: "Write today's progress note for patient 67890, admitted for pneumonia."

Actions:

1. fhir_search Encounter for patient 67890, class=IMP, status=in-progress. Returns ENC-MED-300, admitted 2024-03-13, reasonCode="Community-acquired pneumonia". Today is 2024-03-15 = Hospital Day #3.
2. fhir_read Patient/67890. Returns: Alice Chen, DOB 1965-07-22, Female.
3. fhir_search Observation vital-signs 24h. Returns: Tmax 38.2C (overnight), Tcurrent 37.1C, HR 78-92 (current 82), BP 118-132/68-78, RR 16-20, SpO2 94-97% on 2L NC.
4. fhir_search Observation I&O. Returns: Intake 2400mL, Output 1800mL, Net +600mL.
5. fhir_search Observation laboratory 24h. Returns: WBC 11.2 (down from 15.8), procalcitonin 0.8 (down from 2.1), BMP normal.
6. fhir_search DiagnosticReport 24h. Returns: CXR - "Right lower lobe consolidation, improved from prior."
7. fhir_search MedicationRequest active. Returns: ceftriaxone 1g IV daily (day 3), azithromycin 500mg PO daily (day 3), enoxaparin 40mg SQ daily, pantoprazole 40mg IV daily, acetaminophen 650mg PO q6h PRN.
8. fhir_search Condition active. Returns: CAP (J18.9), HTN (I10), T2DM (E11.9).

Result:

DAILY PROGRESS NOTE
====================
Patient: Alice Chen | MRN: MRN-67890 | DOB: 1965-07-22 (Age: 58)
Date: 2024-03-15 | Hospital Day #3 | Admitting Dx: Community-acquired pneumonia

24-HOUR VITALS
Tmax: 38.2C (overnight) -> Tcurrent: 37.1C [IMPROVING - fever curve trending down]
HR: 78-92 (82) | BP: 118-132/68-78 | RR: 16-20 | SpO2: 94-97% on 2L NC

I&O: Intake 2400mL | Output 1800mL | Net +600mL

LABORATORIES
WBC: 11.2 [DOWN from 15.8 - improving]
Procalcitonin: 0.8 [DOWN from 2.1 - improving]
BMP: Within normal limits

IMAGING
CXR (today): RLL consolidation, improved from prior

ASSESSMENT & PLAN (by problem)
1. Community-acquired pneumonia (J18.9) - IMPROVING
   - Fever curve trending down, WBC and procalcitonin improving, CXR improved
   - Antibiotics: Ceftriaxone + Azithromycin day 3 of planned 5-day course
   - Continue 2L NC, wean O2 as tolerated

2. Hypertension (I10) - STABLE
   - BP within range on home medications

3. Type 2 diabetes (E11.9) - STABLE
   - Monitor fingerstick glucose

STANDING ORDERS
DVT Prophylaxis: Enoxaparin 40mg SQ daily [ACTIVE]
GI Prophylaxis: Pantoprazole 40mg IV daily [ACTIVE]
Diet: Verify
Activity: Verify
Code Status: Verify

Example 2: Post-Surgical Progress Note

User says: "Progress note for patient pt-444, POD 1 from appendectomy."

Actions:

1. fhir_search Encounter for pt-444, IMP, in-progress. Returns ENC-SURG-88, admitted 2024-03-14.
2. fhir_read Patient/pt-444. Returns: David Kim, DOB 2000-01-15, Male.
3. fhir_search Procedure 24h. Returns: Laparoscopic appendectomy, completed 2024-03-14.
4. fhir_search Observation vital-signs 24h. Returns: Tmax 37.8C, current normal, HR 70-85, BP normal, SpO2 99% RA.
5. fhir_search Observation laboratory 24h. Returns: WBC 9.8 (down from 18.2 pre-op), BMP normal.
6. fhir_search MedicationRequest active + MedicationAdministration 24h. Returns: ketorolac 15mg IV q6h, ondansetron 4mg IV q8h PRN (given x1), enoxaparin 40mg SQ daily, cefazolin 2g IV (single dose, perioperative).

Result: Progress note with POD 1 framing, surgical site assessment flagged for clinician input, diet advancement plan, ambulation status, drain output if applicable, discharge criteria checklist.

Troubleshooting

MedicationAdministration not available on the FHIR server

• This resource is optional in many FHIR implementations. Rely on MedicationRequest with status=active for the medication list.
• Note in the progress note that administered medication data could not be verified. PRN usage will need to be obtained from nursing documentation.
• Check if the encounter-level medication list is available through a different resource type.

I&O data not captured in FHIR Observations

• Intake/output is frequently not stored as discrete FHIR Observations. It may exist only in nursing flowsheets within the EHR.
• Flag as: "I&O: Not available in structured FHIR data -- obtain from nursing flowsheet."
• Do not fabricate I&O values. The note should explicitly state data is unavailable.

DiagnosticReport returns references but no conclusion text

• Follow DiagnosticReport.result references to individual Observation resources using fhir_read.
• Check DiagnosticReport.presentedForm for full text attachments.
• If neither is available, note: "[Study type] performed [date] -- result pending or not available in structured data."

Related Skills

• history-and-physical-generator - For the initial admission documentation
• soap-note-generator - For outpatient encounter documentation
• discharge-summary-writer - For discharge documentation when the patient is ready
• critical-value-alert-generator - For flagging critical lab values found during note assembly