We provide many resources that refer directly to “what to include in documentation”. We don’t often say what “not” to include in documentation. Today we are addressing what not to write in a daily progress note, “Refer to Medical Record” is one of those things. Daily progress notes are intended to provide a written description of the skilled services that were provided to the patient on a particular day. They should reflect the medically necessary care that the patient requires in order to improve in function and attain their goals.