Nursing Progress Note Example
Nursing progress notes are a written record of a patient’s condition and care. Progress notes can be used in many ways, from improving safety to providing educational opportunities for new nurses or physicians. In this article, we’ll go over the basics of what makes up a nursing progress note and how those components work together to provide useful information for any healthcare provider who wants to read them.
This section of the nursing progress note will include subjective data. Subjective data is information that is based on what the patient says. It may be in first person (“I have a pain in my stomach”), second person (“You should get rid of that rash”), or third person (“My fever was so high yesterday”).
The nurse gathers this type of information from asking questions and listening carefully to what the patient tells them. The nurse will then write down their findings in this section, documenting how they were able to gather it so as not to repeat any mistakes when writing up their next progress report!
Objective data – the specific characteristics of a patient’s condition that can be observed, measured, or quantified.
- Patient name: John Doe
- Age: 69 years old
- Weight: 154 pounds (70 kg)
- Height: 5 feet 6 inches (167 cm)
- Temperature at admission to hospital (TAT): 98.1 F (37 C) with a pulse rate of 90 beats per minute and respirations at 16 breaths per minute.
You should begin your nursing progress note with a description of the patient’s condition. Include information about the patient’s vital signs, lab values, and physical exam findings. If relevant to your case, include the patient’s past medical history and surgical history as well.
Nursing is a unique profession in that it requires you to plan for every aspect of your patient’s care. In order for your plan to be successful, you must evaluate the patient’s condition and then develop an appropriate plan that will achieve their goals in a safe and timely manner.
The first step in planning is determining the goal of your patient’s care. For example, if they are experiencing shortness of breath (dyspnea), we will want to determine why they are having difficulty breathing and then develop a plan that addresses this issue. Sometimes this can mean administering oxygen or other medications such as morphine or nitroglycerin. Other times it may require surgery because cancer has invaded the lungs or heart valves causing compression on those structures which prevents adequate blood flow through them into vital organs like kidneys or brain causing severe damage due lack of oxygen supply necessary function normally while still alive.”
Implementation is the process of putting the plan into action. It includes a variety of tasks, such as:
- Teaching clients and/or family members about the treatment plan.
- Assisting in administering medications or other treatments.
- Observing for changes in vital signs, behavior, and physical appearance.
- Documenting each step taken to implement the care plan.
Nursing progress notes are an integral part of the nursing process. They provide a concise record of what has been done, what is planned and any other pertinent information related to the patient’s care.
In this example, we will look at a Nursing Progress Note example from our sample NPN guidebook. In this section, you will learn how to write an NPN based on real examples from our NPN template library
Nurses can use this format to structure their progress notes.
- Use the template to structure your progress notes.
- Include all of the sections in this template: patient, history & risk factors, exam, diagnosis and plan.
- Include chief complaint and problem list if applicable.
This progress note format is a great way to organize your thoughts, but it’s not the only way. There are many different formats available and some nurses may find one more convenient than the other. The important thing is that you choose an organizational method that works for your unique needs as a nurse so that you can provide quality care for your patients.