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Ward Protocols

How to Take Patient's Daily Progress Report

Patient daily progress report needs to be taken twice a day — before morning and evening rounds.

Use the **SOAP** format for structured documentation:

S — Subjective Findings

The patient's side of the story:

  • What they feel about their illness and its progress
  • Their major concerns and problems
  • Examples: wound soreness, not passed stool for 24 hours, blood in vomitus, numbness in a limb

    • Remember: patient's complaints are not always associated with their primary disease. Something else can be more discomforting. What the patient says is always important.

    O — Objective Findings

    Your assessment of how the patient is today:

  • Take vitals: BP, Pulse, Temperature, Respiratory Rate
  • Ask pertinent questions
  • Do relevant clinical examination
  • For diabetic patients: check RBS
  • In surgical wards: note output from all tubes and drains
  • Check for specific signs (e.g., flapping tremors in hepatic encephalopathy)

    • A — Assessment

  • Your clinical impression of the patient's progress
  • Is the patient improving, deteriorating, or stable?
  • Any new concerns?

    • P — Plan

  • Management plan for the next 24 hours
  • Changes in medication
  • Investigations to be done
  • Any consults needed