Inpatient Progress Note Template

Inpatient Progress Note (CPT 99231-99233) Date: 2/1/2026

Interval History (Subjective)

• Overnight/Interval Events:
• Patient Reports:
• ROS:

Physical Examination (Objective)

• Vitals:
• General:
• CV/Resp/Abd/Ext/Neuro:
• Labs/Imaging:

Assessment & Medical Decision Making (99232)

Selection Basis: Medical Decision Making (MDM)

1. Problems:

• 1+ chronic w/ severe exacerbation (High)
• 1 acute illness w/ systemic sx (Mod) 2. Data:
• Indep. interp of test by other (Mod)
• Discussion w/ ext. physician (Mod)
• Review/Order 3 unique tests/docs (Mod) 3. Risk:
• Prescription drug management (Mod)
• Minor surgery w/ risk factors (Mod)

Calculated Level: 99232 (Based on meeting 2 out of 3 categories).

Plan of Care

1. [Primary Diagnosis]:
2. [Secondary Diagnosis]:
3. Prophylaxis:
4. Disposition:

Electronically Signed by: [Provider Name]