Progress Note Example Nursing

This post is intended to show you how to write a progress note example, a section of a nursing document that documents the patient’s condition and care.

Initial patient encounter

• Patient’s name and age:
• Chief complaint:
• Past medical history:
• Social history:
• Present illness (including symptoms, when they began, how often they occur, how long they last):
• Family history (include any genetic or familial issues such as breast cancer, heart disease):
• Review of systems (list any other problems the patient has had in the past or currently):
• Physical exam (list all findings from your physical examination. For example, if you checked the patient’s height and weight on the chart during your initial visit, then list those numbers here.):
• Diagnosis/prognosis (state what conditions you think this patient has based on your exam findings and lab results; also give a prognosis for recovery if possible):

Subsequent patient encounter

• Date and time of visit:
• Name of patient:
• Name of nurse:
• Name of physician:
• If applicable, name the other healthcare providers who were involved in this visit with your patient. This could include physical therapists, respiratory technicians, or others. Remember that each healthcare professional should have their own progress note, so this is where you can record what each person did during your shift. For example: “The physical therapist gave Mrs. Smith a bath at 1pm on Tuesday and then did some range-of-motion exercises with her upper limbs until 2pm.”

Inpatient care

Inpatient care

Patient’s condition: Patient’s condition has been stabilized.

Medications: Antibiotic and pain medications are being administered.

Procedures/tests/lab work: X-rays were taken and blood work was ordered.

Discharge plans: The patient will be transferred to the ICU after an overnight stay in the hospital. Notify family of your patient’s condition? Yes, notify them when you can.

N/A

The N/A indicates that the information is not applicable to a particular aspect of nursing.

In summary, we have discussed the following:

• The initial patient encounter.
• Subsequent patient encounters.
• Inpatient care.