Use of a Standardized Progress Note and Assessment Form for Performance Evaluation and Quality Improvement

Abstract

In addition to filling patient care-related duties, the Nutrition Support Service also serves as a platform for experiential education and training of pharmacy residents, surgical interns, doctor of pharmacy students, and graduate dietetic students. Because of the diversity in experience and training among members of the team and their trainees, a standardized progress note form with a subsequent progress note assessment form was developed to maintain consistency and to ensure a certain level of quality in the daily progress notes written by the trainees. The instructor randomly chose one of the trainee’s patient progress notes for verbal and written evaluation weekly. Twelve trainees from July 2009 to January 2010 were evaluated. A significant improvement in weekly performance scores (from an average score of 74% ± 12% to 91% ± 7% to 96% ± 6%) was noted by the second and third weeks compared with the first week, respectively (P < .001). Trainees were unanimous that this tool facilitated improvement of their clinical skills and ability to write effective daily progress notes.