Sample Of Nursing Progress Notes

Nursing progress notes are the heart of charting in the clinical setting. They provide a record of the patient’s clinical status, and they serve as a communication tool between nurses and other healthcare providers. The four main parts of the standard SOAP note format are Subjective, Objective, Assessment, and Plan. Other formats include BATES (Body systems are assessed at each visit), GROW (growth/developmental milestones), LACE (Levels Of Care Evaluation), POMR (Past medical history), SEPPA (Social history) and SOAPIER (“So What I Eat Every Day”). Always chart immediately after your patient encounter so that you maintain accuracy and completeness of information.

• *Note: You can find more information about Nursing Progress Notes at https://www.medscape.com/viewarticle/876214

Sample Of Nursing Progress Notes

1 The nursing progress note—the heart of charting in the clinical setting

The nursing progress note—the heart of charting in the clinical setting. It is the most important part of your patient’s record and is a record of their clinical status, care plan and nursing interventions.

The nursing progress note provides an accurate, detailed account of what happened during each shift/visit with a particular patient or resident. The nurse documents all assessments, observations, diagnoses and interventions performed during care delivery by either herself or another qualified healthcare provider (e.g., physician).

2 A nursing progress note is a record of the patient’s clinical status.

A nursing progress note is a record of the patient’s clinical status. The nurse gathers information from the patient, other health care professionals and family members, and documents it in an organized fashion. The information gathered may include symptoms, vital signs, physical examination findings, diagnostic tests results and prescribed treatments.

The purpose of a nursing progress note is to provide continuity of care for patients by documenting assessment data; identifying problems or changes in their condition; making recommendations for further treatment or discharge planning; communicating with other members of the health care team; ensuring quality of patient care; providing legal protection against liability when health care needs are not met (DOC-101); supporting reimbursement claims by documenting services provided; and maintaining up-to-date records required by law or social agencies such as state departments of health/child welfare services for licensing purposes

3 The four main parts of the standard SOAP note format are Subjective, Objective, Assessment, and Plan.

The four main parts of the standard SOAP note format are Subjective, Objective, Assessment, and Plan. All notes should have these components in a logical order.

Subjective data is the patient’s own description of their problem or concern. This includes information such as their chief complaint (the most important reason they came to see you), significant symptoms and history of present illness (including past medical problems), family history (including heredity), social history (including living conditions) and psychosocial stressors (both internal and external factors that may be affecting your patient).

Objective data is your own description of your assessment findings after examining your patient. Your objective assessments will include temperature/pulse/respirations; blood pressure; heart rate; liver function tests; kidney function tests etc., depending on what you find in your examination or what diagnostic tests you order for them.

4 Other formats include BATES, GROW, LACE, POMR, SEPPA, and SOAPIER.

Other popular formats for nursing progress notes include BATES, GROW, LACE, POMR, SEPPA and SOAPIER. These mnemonic systems are often used together to help create a nursing assessment that is detailed yet concise.

BATES stands for Subjective (S), Assessment (A), Objective (O) and Plan (P). It was developed by Barbara Bates in the 1960s as a shorthand way to document patient issues in a systematic fashion. For example: “The patient has been experiencing burning pain on urination since last evening. He reports no fever or chills.”

GROW stands for Goal, Reality, Options/Alternatives/Ways Forward and Willingness/Ability To Do Something About It or Next Steps.*

LACE stands for Location(s) of injury or problem; Anatomical description (often abbreviated with an A); Condition of wound or skin area if applicable; Duration of pain/discomfort; Severity rating; Expected Outcome

5 Always chart immediately after patient encounter to maintain accuracy and completeness of information.

When it comes to nursing progress notes, the first step is to ensure that you have a good understanding of what’s going on with your patient. A patient’s history and physical examination are important factors in helping you make decisions when caring for them.

The second step involves making sure that you accurately capture the information you’ve gathered during your assessment. This can be done by charting out any abnormal readings, such as vital signs or lab results, as well as potential diagnoses based on what happened during your encounter with the patient. It’s also important to document any interventions that were taken during this time period (e.g., administering medications).

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In this section, you will write your progress notes.

Closing

We hope this brief introduction to the nursing progress note has been helpful. The importance of documenting patient care cannot be overstated, and we believe it is essential for nurses to know how to create effective documentation that supports their decision making at all times.