Nursing Progress Notes Sample

Nursing Progress Notes Sample

As a nurse, you have to be able to write about patients and their health in a way that provides key information but doesn’t overwhelm the reader. Luckily for you, this is one of the most common types of nursing documentation out there! Knowing how to write progress notes will help you communicate effectively with other members of your team, as well as ensure that your patients receive proper care after leaving your office.

Allergies: NKA (No Known Allergies)

 

Allergies: NKA (No Known Allergies)

Patients allergic to latex, milk and eggs are sometimes prescribed an EpiPen. This is a device that can be used by those who have severe allergies and cannot tolerate the foods they’re allergic to. The patient wears a bracelet that alerts others of their allergy so they don’t accidentally expose them to it while treating wounds, etc.

Medications:

 

Please try to regenerate this section again by clicking Regenerate Content below. These are the medications that have been prescribed to you by your doctor. This is an important section, as it lets you know exactly what you need to take and how often. You’ll also see what side effects may occur if you don’t take these medications correctly. Please try to regenerate this section again by clicking Regenerate Content below.

Assessment:

 

Please click Regenerate Content below to generate this section again. This is a statement of the patient’s condition before and after treatment. This can be used as documentation for insurance or legal purposes if necessary. Please try to regenerate this section again by clicking Regenerate Content below. Conclusion: Please click Regenerate Content below to generate this section again. This is where the doctor will describe your condition. This section may include things like:

What is the nature of your condition?

How long have you been experiencing these symptoms?

What has your medical history been like?

Do you have any other health issues that could be related to this one? Have you taken any medications or supplements that could be related to this condition? How has your diet been lately? Have you experienced any changes in your lifestyle recently that could be related to these symptoms? Does anything make them better (or worse)? What sort of treatments have you tried so far?

Subjective: Per patient the ‘bump’ on the side of his neck is gone and he’s feeling good.

 

Click Regenerate Content below to regenerate this section again.

-What have you tried so far?

-Have you experienced any changes in your lifestyle recently that could be related to these symptoms?

-Does anything make them better (or worse)?

Objective: Patient’s neck lump is no longer present. Patient has a positive attitude about his health.

 

What have you tried so far? -Have you experienced any changes in your lifestyle recently that could be related to these symptoms? -Does anything make them better (or worse)? Subjective: Per patient the ‘bump’ on the side of his neck is gone and he’s feeling good.

Assessment Continuation for Page 2:

 

Objective: Patient’s neck lump is no longer present. Patient has a positive attitude about his health. What have you tried so far? -Have you experienced any changes in your lifestyle recently that could be related to these symptoms? -Does anything make them better (or worse)? Subjective: Per patient the ‘bump’ on the side of his neck is gone and he’s feeling good. Assessment Continuation for Page 3: Regenerate Content

Plan of Care / Discharge Instructions (IMPORTANT – include patient/family education here!): Patient was instructed to follow up with primary care provider in 4 weeks, or sooner if needed. Patient was instructed to return to urgent care if the lump returns or he notices any other significant changes in his condition. Pt was educated on normal signs and symptoms post-operatively. Pt states he understands how to properly care for his surgical incision, and he was handed a copy of discharge instructions. Pt will be contacting PCP as directed above. Pt seems well-informed regarding prognosis and expected recovery course.

 

The patient was advised to return if there are any concerns or questions regarding his condition. Pt will be contacting PCP as directed above. Pt seems well-informed regarding prognosis and expected recovery course.

After reviewing patient’s medical records and speaking with him briefly, it appears that he is ready for discharge. I was able to confirm what his primary care physician has already prescribed for him, which is a course of antibiotics and pain meds. He also understands the need to follow up with his PCP in 4 weeks or sooner should any complications arise from surgery today.

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