How to Write Nursing Progress Notes
Medical professionals keep a record of their patient’s recovery and care by writing nursing progress notes in the form of a narrative. These include important information about the patient as well as serving in some capacity to serve them during that time spent at your clinic or facility for treatment. It also serves as a reference for the doctors and nurses, to update them with regards to their patient’s conditions and changes. In this article, we describe what a nursing progress note is and provide instructions and tips for how to write your own.
- What is Nursing Progress Note?
- What are the Types of Nursing Progress Notes?
- Elements to include in a nursing progress note
- Steps for writing a nursing progress note
- Need Professional Assistance for Nursing Assignment? Contact Us!
What is Nursing Progress Note?
A nursing progress note is a detailed record of all the activities done in caring for your patient. It contains information about the patient’s general condition, treatments, and therapies administered, any changes seen in physical or psychological state, etc. This report provides an easy reference to the doctors and other nurses when they change shifts or are tasked with caring for your patient. This information is also important in the future should your patient file a medical malpractice lawsuit against you for any negligence or misconduct during your care of them.
What are the Types of Nursing Progress Notes?
There are two main types of nursing progress notes. One is for admissions or initial visits. The other is to update care.
Nursing progress notes for admissions
This type of note would include the patient’s admission details, such as their name and age, as well as any allergies or medications that they are taking. It also includes a summary of how a patient presents during an initial visit. For example, if a patient is extremely upset and cannot talk, this would be noted and referred to during the entire course of their treatment. This type of record is very brief and only includes the basic information about a patient’s initial presentation.
Nursing progress notes to update care
These notes are used throughout the course of a patient’s treatment to account for changes in their condition. This will include such things as an increase or decrease in pain levels, nausea, vomiting, etc. It could also include information about how well they can get up from bed or walk around. It also records if the patient has any new complaints or symptoms that may have worsened since their previous visit (and if so what steps were taken to assess and treat). If your facility does not usually write nursing progress notes, then you may not be required to write them, but it’s a good idea to do so since they can provide a valuable record for your patient.
Elements to include in a nursing progress note
Writing a nursing progress note should be done immediately after the treatment of your patient, while all the activities are fresh in your mind. You can then use this as a reference when giving updates about your patient’s condition to their doctors or other medical professionals, whenever they visit for their own tasking (e.g., changing bandages). The nursing progress note should be written using simple language and terminology that anyone who has an interest in understanding them would have no problem. This includes not making it too long to read, so keep your words concise but filled with important details regarding what happened throughout the course of treatment.
In order to keep a nursing professional’s notes on track and clear, you must include the following elements:
- Patient’s name, age, and medical record number – This helps you ensure that you’re talking about the same person throughout your report.
- Time and date of visit – These allow other medical professionals to know what stage in the patient’s treatment they’re looking at.
- Doctor and nurse’s name – This identifies who is responsible for providing care and treatment.
- Medical condition – The first thing to the state should be what conditions brought your patient to the facility, as this is usually the most important and relevant information
- Details of treatment – This includes medications given and any specific treatments like:
Vital signs – These include blood pressure, heart rate, respiratory rate, etc.
Assessments – These include a detailed description of the condition you’ve observed, as well as how it’s been changing since the last report.
Patient education – It is important to be updated with any information given by your patient about their condition and treatment so that you can share them with other doctors. For example, if your patient tells you that they have an upcoming surgery or just bought medication from another medical professional, then this should be included in the note.
Explanation of alerts – If there are changes in behaviour or physical symptoms noticed during treatments/medications administration, then you should describe what happened and who was involved (i.e., yourself or other nurses).
- Any significant changes seen in the patient – This includes changes in the patient’s condition, medications required, etc.
- Any potential risks or harm done to your patient – These are complications or injuries that could have been prevented had you been more careful with your patients.
- Instructions for further care – If there are any activities, treatments, or medications that need to be done after you leave the patient’s side, then these should be included in your progress note.
Writing a nursing progress note under pressure and without referring back to any other reports/documents can be stressful and difficult.
Steps for writing a nursing progress note
Nursing progress notes are a great way to document the care of your patient. However, not all nurses use this same format when writing their nursing notes so it’s important that you know how SOAPI works in order for them be effective and beneficial! SOAPI stands for subjective, objective, assessment, plan, and interventions. The SOAPI method is a way to write progress notes. It should be followed in this order:
- Subjective – You should begin by writing down what symptoms or signs your patient is having. In this section, you include what your patient has been saying about their condition/treatment. If they’ve been complaining about pain or discomfort due to a wound or pressure on a wound or incision from dressing changes, then that should be included here too.
- Objective – Include any observable signs and symptoms that may have changed throughout treatment with any medications and treatments given in the interval between visits (e.g., if you gave an additional dose of medication but there is no increase in blood pressure reported).
- Assessment – This includes your evaluation of how these signs and symptoms can affect your patient’s recovery. Here, you will include information such as lab reports, diagnostic screenings, treatments given, etc. If possible, try to use as much evidence as possible to support your assessment statement. For example, if a fever is causing the pain because your patient has inflammatory arthritis and you haven’t seen any improvement in their wounds or incisions, then this information should be included in the assessment section of the note.
- Plan – This is where you describe what changes have been made to your patient’s treatment/medications administration based on these signs and symptoms. If the primary cause of discomfort continues to be from inflammation that increases with movement, then you may add anti-inflammatory medications to reduce movement that will also help decrease the pain. In addition, dressing changes could be scheduled every 3 days instead of daily because there are no visible signs of infection present.
- Interventions – In this last section, you need to summarize all actions that were taken during the encounter with your patient. This should include medications you gave/prescribed, treatments given, activities completed or supervised by yourself or other nurses, etc. Anything done before, during, or after a visit can be included here (e.g., phone calls, medication administration, patient education like wound care or specific exercises).
In order for you, nursing progress notes to be effective and beneficial it is important that they are well written and organized. The SOAPI method helps you organize a comprehensive nursing note but always make sure to include as much relevant information as possible!
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