Progress Note Nursing Example

Progress Note Nursing Example

Subjective: The patient appears to be in good spirits and has no complaints today. Objective: Joints appear to be stable with no signs of edema, inflammation, or drainage. Assessment: Vital signs are within normal limits; there are no obvious signs of infection or abuse. Plan: I will continue to monitor for swelling, pain and redness (or other signs) as well as vital signs throughout the day/weekend.

Subjective: ‘No complaints today.’

The subjective section should explain how you feel and what you’re doing. This is an opportunity to use your own voice to show the reader that you’re not just another robot following directions, but someone who’s engaged with their life and can communicate their feelings.

You might write something like:

  • Yesterday I had a fever, but I’m feeling much better today! I drank lots of fluids yesterday and today, including water, juice, tea and soup. It was hard to get out of bed in the morning because my muscles were sore from being ill yesterday; however I drank some coffee before getting up and felt much better afterwards!

Objective: ‘No signs of joint pain or edema.’

Objective: ‘No signs of joint pain or edema.’

Joint pain is a common symptom of many diseases, including Lyme disease and rheumatoid arthritis. Edema is a common sign of heart failure and can be measured using the ankle-brachial index.

Assessment: ‘No obvious signs of infection or abuse.’

Assessment: ‘No obvious signs of infection or abuse.’

The patient’s vital signs are normal, and the patient shows no signs of pain, swelling or edema in any area. The patient is alert and oriented to person, place, time and event.

Plan: ‘Will continue to monitor for swelling and infection.’

  • Plan: ‘Will continue to monitor for swelling and infection.’
  • Reason: The patient is not showing signs of swelling or infection. The patient has not shown any signs of pain, abuse or infection.

This is an example of a progress note that a nursing student might write up after observing a patient.

  • The patient is awake and appears to be in no distress.
  • The patient’s vital signs are stable, with a temperature of 36.1 degrees Celsius (97.0 Fahrenheit), a heart rate of 78 beats per minute, and a respiratory rate of 18 breaths per minute.
  • I observed the patient eating lunch today at 12:00 p.m., 20 ounces of chicken noodle soup and half a sandwich from Subway (turkey breast). After eating lunch, the patient has been sitting quietly for about an hour now watching television in his room on channel 3 (General Hospital).

In the nursing world, progress notes are a way to document your observations and plan of care for patients. They’re important because if you don’t write them down, how will anyone know what happened? The progress note example we’ve given here is just one example of how this type of note might look—but as long as it’s clear and concise, any format should be fine!

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