(5) The final progress note should record the patient's general condition upon
discharge and the final diagnosis. In addition, it should prescribe post discharge care
(6) In hospital death cases, the final note should describe the terminal
circumstances, findings, and final diagnosis and should state whether or not an autopsy
(7) The frequency of progress notes depends on the condition of the patient.
During the acute phase of the illness, the progress notes should be written every day or
even every few hours (very seriously ill/seriously ill patients, at least once a day or more
often). For surgical patients, there must be a daily note for at least the first four
postoperative days. For convalescent patients and fracture patients with no complications,
notes are not needed as often as for patients receiving active treatment. In no case should
more than seven days pass without a progress note.
1-14. DOCTOR'S ORDERS AND NURSING NOTES
a. Use of DA Form 4256. DA Form 4256 (Doctor's Order) is used to convey the
actions the doctor wants for the patient. This form is a three-copy, carbonless form. The
original copy (white) remains with the patient's permanent record. The second copy (pink)
is sent to the pharmacy, where it is kept until the patient is discharged. The ward copy
(yellow) is used to give orders to the nursing staff. Figure 1-10 shows a DA Form 4256
with the doctor's order entered.
(1) Preparation. All entries are made with a ballpoint pen using blue-black or
black ink. The patient identification must be completed in each section using the admitting
(2) Method of writing orders. More than one order may be written in each
section of the form but not more than one may be written on a single line. The prescriber
must record the date and time each order is written. Each order must be accounted for
separately. All orders must be dated and signed by the doctor.
(3) Method of accounting for orders. Actions taken to comply with written orders
will be accounted for in the far right column of the form entitled "List Time Order Noted and
Sign" column. The nurse or clerk noting the order must list the time orders are noted and
sign or initial his entry. When two or more orders are noted, the nurse may enclose the
orders in a brace, list the time orders noted, and sign or initial his entry.