Clinical Words to Use in Progress Notes

Progress notes are a part of everyday clinical work. They tell the ongoing story of a patient’s care and progress. A strong note is clear, accurate, and easy to understand. It helps you remember important details, allows your care team to understand the situation quickly, and supports safe, ethical care. Still, finding the right words can be difficult. Many clinicians repeat the same phrases or write longer notes than needed, which can make documentation less clear.

In this blog we will focus on practical clinical words you can use in progress notes to improve clarity and professionalism without making your writing sound complex. The goal is simple: effective language that clearly shows what you observed, what actions you took, and what you plan to do next. Good notes are not about using big words, they are about using the right words to create a clear clinical picture.

The Foundation – What Are Progress Notes?

First, what is a progress note? It is a legal document. It tracks a patient’s health status, care, and results over time. Every time you see a patient, you write a note. Doctors, nurses, therapists, and social workers all write them.

A great note follows a simple structure. Many people use the SOAP format:

• S: Subjective. What the patient tells you. Their symptoms, feelings, and history.
• O: Objective. What you see, hear, measure, or test. The facts.
• A: Assessment. Your professional judgment. What do you think is going on?
• P: Plan. What will you do next? Treatment, tests, or follow-up.

We will find words for each of these parts. Using a structure like SOAP makes your notes consistent. This helps everyone on the team find information quickly.

The Subjective (S) Section – Capturing the Patient’s Story

This section is the patient’s voice. You are reporting what they said. Use phrases like “Patient reports…” or “Patient states…” to show this.

Instead of saying: “The patient said their stomach hurts.”

You can write: “Patient reports diffuse abdominal discomfort.”

Here are better words for common symptoms:

Pain:

• Ache: A dull, constant pain. (e.g., “Reports a dull ache in lower back.”)
• Discomfort: A milder, general term for feeling unwell or in pain.
• Tenderness: Pain when an area is touched.
• Sharp/Stabbing: Sudden, intense pain.
• Throbbing: Pain that beats in rhythm with the heart.
• Cramping: Tight, squeezing pain, often in the abdomen.

Common Symptoms:

• Fatigue: Extreme tiredness (better than just “tired”).
• Malaise: A general feeling of being unwell.
• Nausea: Feeling like you need to vomit.
• Shortness of breath (SOB): Difficulty breathing.
• Dizziness: Feeling lightheaded or unsteady.
• Vertigo: The feeling that the room is spinning.

Describing History:

• Denies: Says something is not present. (e.g., “Denies chest pain or fever.”)
• Indicates: Points to or suggests. (e.g., “Social history indicates a 10-pack-year smoking history.”)
• Adheres to: Follows as directed. (e.g., “Patient states they adhere to the medication regimen.”)
• Compliant/Non-compliant: Following or not following the treatment plan. (Use these terms carefully and factually)

Key Tip: Always put the patient’s words in quotes if they are exact. For example: Patient states, “I feel a sharp pinch in my side when I take a deep breath.”

The Objective (O) Section – Reporting Your Findings

This is the fact section. Only write what you can observe or measure. Be specific and neutral.

General Appearance:

Instead of “looks bad,” be descriptive:

• “Patient is alert and oriented to person, place, and time.” (A&Ox3)
• “Patient appears fatigued, with slow speech.”
• “Patient is in obvious distress, clutching abdomen.”
• “Patient is well-groomed and making good eye contact.”

Vital Signs & Measurements:

Use the standard terms:

• Afebrile: No fever.
• Febrile: Having a fever.
• Normotensive: Normal blood pressure.
• Hypertensive/Hypotensive: High/low blood pressure.
• Tachycardic/Bradycardic: Fast/slow heart rate.
• Tachypneic/Bradypneic: Fast/slow breathing rate.
• Saturating: Referring to oxygen levels. (e.g., “Saturating 98% on room air.”)

Physical Exam Words:

This is where strong vocabulary is very important.

• Inspection: Looking at the body.
  • Erythema: Redness.
  • Ecchymosis: Bruising.
  • Edema: Swelling from fluid.
  • Lesion: A general term for an area of damaged skin.
  • Atraumatic: Without injury; normal appearance.
• Palpation: Feeling with your hands.
  • Firm / Soft / Boggy: Describing texture.
  • Mass: A lump.
  • Rigidity: Stiffness of the muscles.
  • Guarding: Tightening muscles to protect an area from being touched.
  • Rebound tenderness: Pain that is worse when you quickly release pressure.
• Percussion: Tapping to hear sounds.
  • Resonant: A normal, hollow lung sound.
  • Dull: A flat sound, heard over solid areas like the liver.
• Auscultation: Listening with a stethoscope.
  • Lungs: Clear, diminished, wheezes, rhonchi (low-pitched sounds), crackles/rales (fine, crackling sounds).
  • Heart: Regular rate and rhythm (RRR), murmur, gallop.
  • Bowel sounds: Present, hyperactive, hypoactive, absent.

Mental Status Exam:

• Affect: The visible expression of emotion (e.g., “Flat affect,” “Congruent affect”).
• Mood: The patient’s reported emotional state (e.g., “Reports depressed mood”).
• Speech: Pressured (fast, urgent), slow, clear, slurred.
• Thought process: Logical, linear, tangential (wandering off topic).

The Assessment (A) Section – Your Clinical Thinking

This is your professional conclusion. It sums up what you think is happening.

Instead of: “I think it’s an infection.”

Write: “Assessment: Acute bacterial sinusitis.”

Words to Describe the Problem:

• Acute: New, sudden, or short-term.
• Chronic: Long-standing or ongoing.
• Exacerbation: A flare-up or worsening of a chronic condition.
• Improving / Resolving / Worsening / Unchanged: The status of the condition.
• Etiology: The cause or origin of a disease.
• Differential Diagnosis (DDx): The list of possible conditions that could explain the symptoms.

Stating Your Diagnosis:

• “The presenting symptoms are consistent with migraines.”
• “Findings are suggestive of a urinary tract infection.”
• “This likely represents a flare of rheumatoid arthritis.”
• “Rule out (R/O) pneumonia given fever and cough.”

The Plan (P) Section – The Roadmap Forward

This is your action plan. It must be clear so the patient and the team know what to do.

Diagnostic Plan:

• “Obtain a complete blood count (CBC) and metabolic panel.”
• “Schedule an echocardiogram for further evaluation.”
• “Order a chest X-ray to rule out pneumonia.”

Therapeutic Plan (Treatment):

• “Initiate a course of amoxicillin 500mg three times daily for 7 days.”
• “Increase the dosage of lisinopril to 10mg daily.”
• “Continue current medications and monitor for side effects.”
• “Discontinue the use of naproxen due to gastric discomfort.”
• “Refer to physical therapy for gait training.”
• “Counseled patient on low-sodium diet options.”

Patient Education:

• “Educated patient on warning signs requiring immediate return.”
• “Reviewed proper insulin injection technique.”
• “Provided handout on deep breathing exercises.”

Follow-Up:

• “Follow up (F/U) in clinic in 2 weeks to assess progress.”
• “Return to clinic (RTC) as needed (PRN) for worsening symptoms.”
• “Admit to hospital for IV antibiotics and monitoring.”
• “Discharge home with home health services.”

Putting It All Together – Progress Note Example

Let’s see how these words create a clear, professional note.

Chief Complaint: Abdominal pain.

S: Patient reports a sharp, cramping pain in the lower abdomen that began 12 hours ago. Describes pain as 7/10 in severity. Also reports nausea and two episodes of non-bloody vomiting. Denies fever, diarrhea, or urinary symptoms. States last bowel movement was normal yesterday. Admits to similar, milder episodes in the past.

O:

• Vitals: T 98.6F, BP 128/78, HR 88, RR 14, SpO2 99% RA.
• Gen: Patient is alert but appears uncomfortable, lying still in bed.
• Abdomen: Soft, with moderate tenderness to palpation in the right lower quadrant. Positive for guarding. No obvious masses. Bowel sounds are hypoactive.

A:

1. Acute abdominal pain. Findings are highly suggestive of acute appendicitis.
2. Nausea and vomiting, likely secondary to #1.

P:

1. Obtain stat CBC, CMP, and urinalysis.
2. Order CT abdomen/pelvis with IV contrast for confirmation.
3. Consult the General Surgery service for evaluation.
4. Keep patient NPO (nothing by mouth) in anticipation of possible surgery.
5. Provide IV fluids for hydration and IV Zofran 4mg for nausea.
6. Will update patient and family after test results and surgical consult.

Words to Avoid and Why

The words we choose do more than convey information; they set a tone, imply judgment, and can significantly shape how the patient and future providers perceive the clinical encounter. Choosing language that is both precise and respectful is a cornerstone of professional, ethical documentation. Here are words and phrases to use with caution, and what to use instead.

• “Claims,” “Alleges,” or “Insists”:
  • Why to Avoid: These words carry a heavy implication of doubt or skepticism. They subtly suggest you do not believe the patient, which can damage rapport, create defensiveness, and undermine the patient’s voice in their own record. This language can also be seen as prejudicial.
  • Better Choice: Use neutral, factual alternatives.
  • Instead, write: “Patient states, reports, or describes a history of headaches.”
• “Complains of” or “Is complaining of”:
  • Why to Avoid: While still common, “complains” can have a pejorative or negative connotation, framing the patient’s symptoms as an annoyance rather than a valid medical concern. It can inadvertently paint the patient in a difficult light.
  • Better Choice: Use objective language focused on the presentation itself.
  • Instead, write: “Patient reports abdominal pain,” or “Patient presents with shortness of breath.”
• “Poor” or “Unreliable Historian”:
  • Why to Avoid: This is a broad, judgmental label that fails to convey useful information. It doesn’t explain why the history is challenging and can be disrespectful. The difficulty may stem from the patient’s medical condition (e.g., dementia, delirium), emotional state, language barrier, or cultural factors.
  • Better Choice: Describe the specific circumstance factually and without blame.
  • Instead, write: “Patient’s recall of event sequence is inconsistent,” or “History is limited due to patient’s altered mental status,” or “Collateral history obtained from daughter due to patient’s severe dementia.”
• “Refuses,” “Non-compliant,” or “Uncooperative” (as a label):
  • Why to Avoid: These are inflammatory terms that frame care as a power struggle and assign blame to the patient. They do not reflect the shared decision-making process. “Non-compliant” is a particularly loaded term that ignores the myriad reasons a patient might not follow a plan (cost, side effects, misunderstanding, cultural beliefs).
  • Better Choice: Document the shared decision-making process. State what was offered, the education provided, and the patient’s informed choice. Use “declined” for a specific intervention.
  • Instead, write: “Risks, benefits, and alternatives of the recommended surgery were discussed at length. Patient declined the procedure at this time, opting for continued medical management.” Or, “Patient is experiencing financial barriers to obtaining the prescribed medication.”
• “Appears” or “Seems” (when used vaguely):
  • Why to Avoid: Using these words without concrete supporting evidence is weak and subjective. “Patient appears anxious” is an interpretation. It’s more valuable to document the objective signs you observed that led to that conclusion.
  • Better Choice: State the observable behaviors, then give your assessment if relevant.
  • Instead, write: “Patient is pacing, wringing hands, and reports feeling overwhelmed. This is consistent with anxiety.“
• “Normal” or “WNL” (Within Normal Limits):
  • Why to Avoid: In a physical exam, “normal” is often too vague. What was normal? A future provider needs specifics. “WNL” is an outdated abbreviation that is best avoided.
  • Better Choice: Be specific about your findings, even if they are unremarkable.
  • Instead of writing: “Lungs: Normal.”
  • Write: “Lungs: Clear to auscultation bilaterally, with good air movement. No wheezes, rales, or rhonchi.”
• Vague, Non-Quantifiable Terms:
  • Why to Avoid: Words like “a lot,” “better,” “okay,” “stable,” “significant,” or “improved” are meaningless without context. They provide no useful data for tracking progress.
  • Better Choice: Use specific measurements, comparisons, and descriptions.
  • Instead of writing: “Edema is better.”
  • Write: “Lower extremity edema has decreased from +3 pitting to +1 pitting bilaterally.”
  • Instead of writing: “Pain is okay.”
  • Write: “Patient rates pain as 2/10 at rest with current analgesia, down from 7/10 yesterday.”
• Emotionally Charged or Colloquial Language:
  • Why to Avoid: Words like “freaking out,” “hysterical,” “demanding,” or “drug-seeking” are unprofessional, stigmatizing, and not clinically useful. They document your emotional reaction, not the patient’s condition.
  • Better Choice: Stick to observable behavior and clinical assessment.
  • Instead of writing: “Patient is hysterical and demanding pain meds.”
  • Write: “Patient is crying, speaking in a raised voice, and repeatedly requesting analgesia. Behavior suggests acute distress and difficulty coping with pain.” Document your objective pain assessment findings separately.

Tips for Excellent Notes

Here are the six key habits that separate good notes from great ones. These are not just suggestions; they are essential practices for safe, effective, and professional patient care.

Be Timely: Write Your Note as Soon as Possible After Seeing the Patient. Memory Fades Fast.

Why is this so important? Think of your memory like a sandcastle on the beach. The details, the exact words the patient used, the specific location of a rash, a subtle finding on exam, are the intricate shapes. With every passing minute, the tide of new thoughts, tasks, and interruptions washes over it. Fine details blur and are lost.

• The Risk of Delay: Waiting even a few hours can lead to vague notes. “Chest pain” becomes “some discomfort.” A patient’s precise description of pain, “like a tight band,” becomes just “pressure.” You might forget to document a key symptom they denied or an important instruction you gave. This loss of detail is a direct loss of quality care.
• Best Practice: Make documentation part of the visit flow. For many, this means writing the note with the patient present (on a computer, in the room). This lets you confirm details with them in real-time: “So, you’re saying the dizziness happens mainly when you stand up?” It’s more accurate and engages the patient. If you must document later, set a hard rule: notes must be completed before you see your next patient, or at the absolute latest, by the end of your shift. Your future self, your colleagues, and your patient will thank you.

Be Accurate: Double-Check Drug Names, Doses, and Lab Values.

Accuracy is non-negotiable in healthcare. A progress note is a legal record and a communication tool for action. An error here can lead directly to a medical error.

1. The Danger of “Close Enough”: There are many drug names that sound alike or look alike (e.g., Celexa vs. Celebrex, hydralazine vs. hydroxyzine). A typo in a dose (“.5 mg” versus “5 mg”) can be deadly. Transposing lab values can misrepresent a patient’s entire condition.
2. Best Practice: Adopt a “trust but verify” habit.
   • For Medications: Look directly at the patient’s medication bottle, the hospital MAR (Medication Administration Record), or the pharmacy list. Do not rely on your memory or a previous note. Spell out the drug name clearly and include the exact dose, route, and frequency.
   • For Lab/Test Results: Do not type numbers from memory. Copy and paste directly from the electronic health record (EHR) system if possible, or look directly at the report and type carefully. Verify patient identifiers on the report match your patient.
   • For Patient History: Double-check dates, surgical names, and allergy specifics. A second of verification prevents hours of confusion or harm.

Be Concise: Use Bullet Points. Keep Sentences Short. Avoid Long Stories.

Your colleagues are busy. They need to find critical information in seconds, not read a novel. Conciseness is about respect for your reader’s time and clarity of thought.

1. The Problem of Narrative: Long paragraphs with complex sentences bury the important facts. The key finding can get lost in a story about what the patient ate for breakfast.
2. Best Practice:
   • Use Bullets and Headings: The SOAP format itself is a heading system. Use bullet points under each section, especially for Objective findings and the Plan. This creates visual “white space” that makes notes easy to scan.
   • Write in Telegraphic Style: It’s okay to drop pronouns and articles in the Objective section. Instead of “The patient’s lungs were clear to auscultation bilaterally,” write: “Lungs: Clear bilaterally.”
   • Stick to Relevant Facts: Document what matters for the current problem. The patient’s knee surgery 20 years ago may not be relevant to their new onset of ear pain. Ask yourself: “Is this information necessary for decision-making today?”

Use Abbreviations Carefully: Only Use Standard, Approved Abbreviations. When in Doubt, Write It Out.

Abbreviations save time, but they are a major source of medical error. What is clear to you might be confusing or dangerous to someone else.

1. The “U” and “Zero” Problem: The classic example is writing “U” for “units,” as in “10U of insulin.” A hurried reader might see “100.” This has caused fatal overdoses. This is why “units” must always be written out.
2. The List of Dangerous Abbreviations: Every hospital has a “Do Not Use” list. Common banned abbreviations include:
   • QD (daily) – Can be mistaken for QID (four times daily). Write “daily.”
   • Trailing zeros (5.0 mg) – Could be read as 50 mg. Write “5 mg.”
   • Lack of leading zero (.5 mg) – Could be read as 5 mg. Write “0.5 mg.”
   • MS, MSO4, MgSO4 – Is this morphine sulfate or magnesium sulfate? Spell it out.
3. Best Practice: Know and follow your institution’s official abbreviation policy. If you are unsure if an abbreviation is approved or could be misunderstood, always write the full word. Clarity and safety are always more important than saving two seconds.

Never Leave Blanks: If Something is Not Done, Write “Not Assessed” or “Deferred.” A Blank Can Mean You Forgot.

A blank space in a note is ambiguous and risky. It leaves everyone guessing.

1. The Guessing Game: Did you forget to do the exam? Did you do it and forget to write it? Did you intentionally skip it? A colleague reviewing the note or covering for you has no way of knowing. They might waste time repeating an exam you already did, or worse, assume a finding was normal when it was never checked.
2. Best Practice: Actively document the status of every standard part of your assessment.
   • If you did not listen to the patient’s heart because the visit was for a skin laceration, write: “Cardiac: Not assessed in this focused exam for dermatologic complaint.”
   • If you plan to do something later, write: “Neurologic exam deferred due to patient agitation; will re-attempt in 2 hours.”
   • This practice shows you were thorough and deliberate. It creates a clear record of what was and was not done, which is critical for both continuity of care and legal protection.

Proofread: Check for Spelling and Grammar Errors. They Can Confuse Others and Look Unprofessional.

You are a professional, and your documentation should reflect that. Sloppy notes undermine confidence in your clinical care.

1. Errors Cause Confusion: Misspelling a drug name can lead to the wrong drug being given. Poor grammar can change the meaning of a sentence. “The patient could not tolerate the medication” is very different from “The patient could not tolerate the medication.”
2. It’s About Professionalism: A note filled with typos and errors sends a message that you were rushed, careless, or did not value the task. It can erode trust with patients who read their notes and with colleagues who rely on your work.
3. Best Practice: Take 60 seconds at the end of every note to read it over. Do not just skim. Read it word-for-word. Better yet, use the text-to-speech function on your computer, hearing the note read aloud catches errors your eyes might skip over. Look specifically for:
   • Correct patient name and date.
   • Spelling of key medical terms and medications.
   • That your sentences are complete and clear.
   • That your assessment and plan logically follow from your subjective and objective findings.

By making these six tips a consistent habit, you ensure your progress notes are not just a task to complete, but a reliable, clear, and professional foundation for excellent patient care.

The Bottom Line: Your Notes Are Your Voice

Your progress notes are a vital part of patient care. They are your voice when you are not in the room. They tell the story of the patient’s journey. By choosing clear, strong, and precise words, you make that story easy to understand. You don’t need to use every fancy word you know. You just need to use the best word for the job. This guide gives you a strong list to start with. Practice using them. Soon, they will become a natural part of your writing.

Remember, a great note leads to great care. It helps your team. It keeps the patient safe. And it shows your skill and professionalism as a healthcare provider. Keep learning, keep writing, and keep making a difference, one clear note at a time.