If you are a nurse, you know one of the most important parts of our jobs is to document about our patient’s status, the care they receive, and their response to any treatments. There are many types of documentation nurses and other healthcare professionals use. One type of documentation is a nursing progress note. If you are new to nursing or unsure about the different types of documentation, you may wonder, “What is a nursing progress note?”
In this article, I will tell you about nursing progress notes, what they are, their purpose, and the advantages and disadvantages of using them. I will also share 5 perfect nursing progress notes examples + how to write them. At the end of this article, I will answer some frequently asked questions about nursing progress notes to give you more insight into these important documents.
Nursing progress notes are the records used by nurses to document patient changes and progress during hospitalization or while under medical care. A nursing progress note is a crucial record of events that occur in the time during which the patient is under a nurse’s care. The notes are used to compare the patient’s past and current status, communicate with members of the interdisciplinary team, and plan patient care based on the patient’s current needs.
The purpose of a nursing progress note is to relay information between nurses and other healthcare providers about events that occur during patient encounters. Nursing progress notes convey details about the chain of events in patient care directed at achieving anticipated goals and outcomes.
Nursing progress notes are a narrative summary of the care provided by the nurse during a patient encounter. Nursing progress charts include nursing progress notes and other vital information relevant to the patient’s status from admission until discharge. The nursing progress chart may have copies of laboratory and other diagnostic testing, medication records, and copies of the nursing care plan.
Documentation is one of the most important jobs we have as nurses. When we document patient care thoroughly, we create a story that any healthcare professional should be able to follow. The following are three main advantages of using nursing progress notes as a form of documentation.
Well-written nursing progress notes provide detailed information about a patient’s progress for nurses and other healthcare team members to track changes in the patient’s status. When we create progress notes that follow appropriate guidelines and include essential information, any member of our team should be able to read through past notes and determine if the patient is improving with the current plan of care or whether the care plan should be changed to meet their current needs.
Nursing progress notes, when written correctly and in a timely manner, tell a story about your patient that includes vital information. As nurses, we can use the information from progress notes to determine which interventions are effective and whether new or modified interventions will be more effective. By reviewing previous entries from other nurses and comparing the findings from your patient assessments, you can implement measures that promote better patient outcomes.
One thing I always stress to nursing students is something one of my former nursing instructors told me, “If you did not chart it, you did not do it.” Even if you remember providing care to a patient, if you do not document the care, in the eyes of the law, you did not do it. We use nursing progress notes to document changes in our patients from the time they are admitted to our service until they are discharged. Everything we do for them must be carefully documented. Although you may never experience having one of your patients being involved in a medical malpractice or negligence case, there is no way to know for sure. It is always in your best interest to provide the best nursing care possible and then document everything you see and do.
Like any documentation or other nursing tasks, there are some disadvantages to nursing progress notes. The following are two of the main disadvantages of using this type of documentation.
Nursing progress notes should create a detailed account of each patient encounter. When written correctly, it can be time-consuming to complete them. I encourage you, though, to remember that the time it takes to complete your notes is worth it, as the content in progress notes is helpful to everyone on the healthcare team.
Another disadvantage of nursing progress notes is that the information from one nurse’s note to another may seem similar or repetitious. This is especially true if the patient has few changes from one shift to the next. Instead of repeating exact details from a previous note, keep in mind that the note is to document progress, whether it is positive progress or regression in the patient's status. Document any relevant changes and your observations, but keep details clear and concise.
All nursing progress notes should be comprised of specific information. The basic information that should be included in your notes include the date and time, the patient’s name, the attending physician’s name, and your name and title. Additionally, the progress note should follow guidelines that create a storyline detailing the patient’s previous status, current assessment status, and any interventions and responses. When you write a nursing progress note, you should include the following five elements.
One thing I always stress to nursing students or licensed nurses is that the patient is the primary source of information during any patient encounter. No matter the patient’s age, there are some data that come only from the source, the patient. When you write a nursing progress note, the first data you gather is subjective data. Subjective data may be limited by a patient’s knowledge and perspective, but it is still critical to gather the information directly from them. Subjective data include things like why the patient is seeking care, what the chief complaint is, any symptoms they are experiencing, their pain level, and any other concerns they feel are relevant.
Objective data is any information you personally gather from your observation of the patient or from reviewing test results. Objective data include things like the patient’s vital signs, laboratory or imaging test results, and any observable symptoms. Gathering objective data requires paying attention to your patient’s appearance, their affect, and any symptoms that appear to have changed since their initial assessment or the last recorded nursing progress note.
After gathering subjective and objective data, you will record your assessment findings. This part of the nursing progress note reflects information about the patient’s condition based on your assessment and the comparison of your findings to the findings recorded by other practitioners. Your findings should paint a picture of changes in your patient’s overall status from their initial assessment to the current assessment.
For example, you may document, “Patient resting quietly in bed, affect calm compared to earlier reported state of agitation. Skin color has improved with less pallor and is warm and dry to touch.”
Every patient encounter should include planned nursing interventions. Interventions are any course of action that you, the physician, or other healthcare team members will take to help benefit and improve the health outcome of your patient. When documenting planned interventions, be specific about what you (or other team members) will do and document the patient’s response to the proposed plan of care.
All assessments and interventions should be followed by an evaluation of the patient’s response to the plan of care. The patient's response in the nursing progress note should reflect the care provided and the patient’s reaction or response.
For example, if you administered Tylenol for elevated body temperature, your note may say the following. “APAP 325 x2 administered po for c/o headache and oral temp 100.9. After two hours, pt. Reports headache has subsided. Temp now at 98.7 orally.”
Crafting good nursing progress notes requires including some essential elements, but it also means leaving out some things. Knowing what to include in a nursing progress note or omit is important. The following are some elements that should not be included when writing nursing progress notes.
Nursing progress notes are part of a legal document. Therefore, it is essential that we avoid using jargon, which can be challenging to understand. Instead, your nursing note should be written with easily understandable words to promote effective communication among team members but so the content is also clear if it is reviewed by someone for legal purposes.
When we create a nursing progress note, it should paint a clear picture of what is going on with the patient without embellishing the facts. Crafting an accurate note can take some time, especially if your patient has several issues being addressed. Your note should be to the point, addressing relevant issues only.
It is normal for nurses to discuss patient issues during the course of care, including during reports at shift change. However, the nursing progress notes should reflect your observations of your patient and any subjective information provided by the patient, not someone else’s opinions or observations. Instead, each nurse should document their own observations in individual notes.
Every healthcare facility has a list of approved medical abbreviations you may use when documenting patient care. It is vital that you familiarize yourself with your facility’s policies regarding using abbreviations when creating nursing notes. You may wish to refer to the Official “Do Not Use” List published by the Joint Commission when deciding which abbreviations you should use. In an effort to prevent misinterpretation or inaccurate documentation, you may wish to consider limiting medical abbreviations altogether when writing progress notes.
I remember working in a nursing home in my earlier nursing years. One of the nurses I worked with, who had many more years of experience than I, would sit at the nurse's desk and sign off on all the medications in the MARs before going down the hall to administer medications. One day, state inspectors showed up, and when they went with her on her med pass, they discovered she had already documented giving the medicines that they were observing her administer. It caused our facility to be written up, and she was reprimanded. Nursing is a busy job, and it is natural to want to maximize time and get things done as quickly as possible. However, you should never document any care or intervention until after it is completed.
(The following is a step-by-step process to write a perfect nursing progress note.)
When you begin your nursing progress note, you should begin with the date and time the note is being prepared. Also, include the patient's name. Some facilities use electronic notes that you must type the information in, while others require notes to be handwritten. Whichever format you use, be sure to include the little details.
This step is simply an introduction to the patient and should be short and to the point. For example, “John Smith is a 54 y/o white male presenting today with complaints of severe abdominal pain, nausea, and vomiting.”
One of the most important parts of nursing documentation is subjective information, which is gathered directly from the source, your patient, or from family/caregivers. To gather subjective information, you will ask questions relevant to their status. For example, ask your patient if they are experiencing pain or discomfort, if they have any new concerns, and whether they feel the current treatment is helping them.
You will document as follows: “Mr. Smith reports being nauseated and having bouts of vomiting since late last night. He reports significant pain in the lower right abdominal quadrant and states the pain has been unrelieved for several hours.”
When preparing your nursing progress note, you need to record your findings regarding the patient’s condition. Use information drawn from subjective and objective data as well as your personal observations. You may record what medications or treatments were ordered and implemented. Take note of the patient’s appearance, affect, and any changes from admission to the time of this assessment. The next step in writing a perfect nursing progress note is to ensure you obtain objective data. Objective data include your patient’s vital signs, laboratory or diagnostic test results, and any observable symptoms.For example, “Vital signs for Mr. Smith are B/P 150/98, P 90, R 20, Temp 101.4. Rebound tenderness was noted on the right lower abdomen. Skin is pale and clammy; pt is alert and oriented and appears anxious.”
Nursing progress notes should have a detailed description of the care you will provide. Your care plan is based on the patient’s current status, needs, treatment availability, and preferences. In this section of your note, mention any tests or treatments scheduled for the patient.
You may document, “After reviewing test results and performing assessment, Dr. Jones has diagnosed the patient with acute appendicitis and recommends emergency appendectomy. Mr. Smith agrees to the treatment plan. Physician presented consents and explained upcoming pre- and post-surgical procedures and anticipated outcomes. Pt. expresses understanding and desires to continue with surgery; consents signed.”
It is important to document the patient's response to the proposed treatment plan, whether they agree or disagree with the proposed plan. This is important because if the patient expresses an understanding of the proposed treatment plan but is noncompliant, you will have documentation proving you discussed the plan and its importance with them and their response, which covers you if their noncompliance results in a poor health outcome.
"Nursing interventions implemented include initiating NPO orders, notifying dietary of dietary restrictions, and explaining to patient the importance of remaining NPO to reduce the risk of aspiration during surgery. Pt. voices understanding. Pt.'s spouse at the bedside and voiced understanding of NPO and safety precautions pre- and post-surgery.”
Once a plan is established and interventions implemented, the next step is to document the patient’s response. If the patient responds well to treatment, you should document that. If the patient’s response is not what you hoped for, new interventions should be planned, implemented, and then evaluated for effectiveness.
(Below are 5 perfect nursing progress note examples.)
Crafting nursing progress notes takes time and requires paying attention to every detail. The following are a few examples of how to write good nursing progress notes.
Nurse: Dee Whittington, RN
Mr. Turner is a 62 y/o African American male with a history of stage IV chronic kidney disease secondary to polycystic kidney disease, anemia, atrial fibrillation, and hypertension, which is becoming more well controlled. He receives hemodialysis three times weekly. Vital Signs pre-dialysis were B/P 148/86, P 84, R 22, T 98.1, Wt. 256.4 lbs. All labs WNL. 2+ pitting edema BLE. Upon assessment, the AV graft was clotted; blood was drawn for potassium level and INR r/t long-term use of Coumadin.
0950: The lab called to report Mr. Turner's potassium is 6.6. Notified Dr. Shaw, who instructed me to send client to the emergency room. ER notified of the patient en route via private car with daughter, and a report was given to Nurse Wilson, RN.--------------------------D. Whittington, RN
Nurse: Jason Holyfield, RN
Mary Smith is a 45 y/o white female admitted to the Behavioral Health Unit for complaints of “people talking in her head.” Ms. Smith has a history of Bipolar Disorder and Paranoid Schizophrenia. Although there has been no significant sign of decline since admission, Ms. Smith has shown little sign of positive improvement since the last assessment. Vital signs upon assessment are as follows: B/P 130/78, Apical Pulse 72, Resp. 18, Temp. 98.1, Weight 187 lbs. Ms. Smith is non-aggressive with a flat affect. Although she attends group sessions and activities, her participation is minimal to none. She shows little interest in people or activities in her surroundings. She appears depressed, speaking with a slow, monotone voice, walking slowly, and showing little interest in self-care, as evidenced by disheveled clothing and unbrushed hair. Ms. Smith reports feeling sad and angry because the people in her head will not stop talking, but she denies suicidal ideations or intentions. She reports the voices are especially loud when she tries to sleep unless she takes "that new sleep medicine." She states if she does not take her sleep medication, the “people talk to my head all night.” She was recently prescribed Ambien CR, as needed at bedtime, to help with sleeplessness and appears more rested on the mornings following its use. She reports having a dry mouth and was instructed this is a side effect of Ambien. I encouraged adequate fluid intake and routine oral hygiene to help with dry mouth symptoms. No other changes or concerns were noted. Notified Dr. Hughes, the attending psychiatrist, of Ms. Smith's continued reports of hearing voices and my observation that she may also be experiencing visual hallucinations. Awaiting response at this time.-Jason Holyfield, RN
Nurse: Allison Wilks, RN
Mark Snow is a 70 y/o black male admitted to home health services for wound care of previously untreated decubitus ulcer. The patient is alert and oriented and denies complaints of pain or new concerns. Vital Signs: B/P 128/80, P 72, R 16, Temp 98.6. The Stage 2 decubitus ulcer, with partial thickness and located in the lower sacral region, measured 5 cm x 4 cm upon admission. Today, the wound measures 4 cm x 2.5 cm. The wound shows an improved presence of red granulation tissue and minimal drainage. Instructed Mr. Snow's wife on how to perform dressing changes, as she will change his dressings between nurse visits and prn. Mrs. Snow performed wound care by return demonstration, cleansing the wound with normal saline, patting it dry, and applying a silver-impregnated foam dressing, as per orders. Educated the patient and caregiver on the importance of keeping the wound clean and dry and ensuring frequent position changes to reduce pressure on the affected area. Also discussed signs and symptoms of infection, including foul odor, increased pain, tenderness, redness, or purulent draining, and instructed to notify the attending physician or home health if these symptoms occur. Both Mr. Snow and Mrs. Snow voice their understanding. There are no other changes in patient status or orders at this time. ----------Allison Wilks, RN
Nurse: Margo Littleton, RN
Mr. Jones is an 81 y/o white male admitted to hospice for palliative care services related to diagnoses of Chronic Obstructive Pulmonary Disease, Stage IV Lung Cancer, and Congestive Heart Failure. The patient is currently living in his home with his son and daughter rotating weekly stays with him. Vital signs today: B/P 150/88, P 74, R 26, T 98.2. The patient is on 02 per nasal cannula at 2L/min continuous; no skin irritation or breakdown was noted on ears or nares from the nasal cannula. Bilateral wheezes were noted on auscultation, and patient reports a continued productive cough with thick yellowish-brown sputum. 3+ pitting edema noted in bilateral lower extremities. The patient is prescribed Lasix 40 mg. each morning but states he forgot to take it the last two days. Instructed patient and caregiver on the importance of medication compliance to prevent exacerbation of symptoms. Mr. Jones states he is “tired of living like this.” Denies thoughts of suicide but states he is "ready to go." Notified attending physician of depression symptoms and notified bereavement coordinator to request a bereavement visit be scheduled. The bereavement coordinator states she will see Mr. Jones tomorrow morning to offer support. Educated caregiver on signs and symptoms of worsening disease processes and symptoms of worsening depression. Also, I provided the patient and caregiver with contact information for the on-call nurse for after-hours concerns. Increasing CNA visits to five times weekly for added support. I will follow up with the bereavement coordinator and nursing assistant after their visits tomorrow to decide if nurse visits should also be increased. No other concerns/problems have been noted at this time.-------------Margo Littleton, RN
Nurse: Alton Vickery, RN
Ms. Jones is a 28 y/o white female presenting to the emergency department with complaints of shortness of breath lasting longer than two hours. She has a history of asthma, which is usually well-controlled. She is alert and oriented, denies pain but does express some chest discomfort when trying to take a deep breath. Skin is W&D, good turgor, no compromised skin integrity noted. Vital Signs: B/P 140/90, P 84, R 24 shallow, T 99.1. Shortness of breath and bilateral wheezes were also noted. Pt. Reports productive cough with thick white sputum. Spirometry Level: 76%; Pt. Diagnosed by Dr. Chan with asthma exacerbation and bronchitis. Administered Albuterol 1/25 mg/3ml via nebulizer, as ordered by MD. After 10 minutes, pt. reassessed, and breathing is less labored; pt. seems more relaxed. Ms. Jones stated she let her asthma medication run out and forgot to call her primary care physician for a refill. Sent prescription refill for Albuterol inhaler 90 mcg per actuation to pt's primary pharmacy, per order, and educated pt. on importance of medication compliance and keeping follow-up appointments with PCP. Pt. Voiced understanding. Discharged to home with an education packet on the prevention of asthma exacerbation and scheduled an appointment with her primary care physician for follow-up.----------------------A. Vickery, RN
Writing good nursing progress notes takes time and patience. While every detail regarding your patient’s status matters, you need to know which details are relevant to the case at hand and how to document them. Knowing what to focus on and how to present the information is essential if you want to avoid documentation mistakes. The following are seven of the most common mistakes to avoid while writing nursing progress notes.
Because nursing progress notes tell a story, it is easy to get caught up in writing and embellish the notes with information or content that is not relevant to the patient’s current assessment or situation.
The best way to avoid this mistake is to focus on the situation at hand. Your note should be to the point and concise, recording any new symptoms or complaints, and documenting laboratory or diagnostic test results and the patient’s response to interventions.
One thing I have learned in my years of nursing is that it is easy to jump to conclusions or make assumptions about a patient or their situation. While none of us intends to do so, if we are not mindful, it can happen. When we make assumptions about what a patient is thinking, feeling, or experiencing, it limits our thinking and, therefore, our ability to set and help promote positive patient outcomes.
When creating a nursing progress note, we should rely upon measurable data. To reduce the risk of making assumptions, carefully consider both subjective and objective data and use that data to create a note that conveys what is happening with the patient based on facts and evidence.
One of the first classes we take in nursing school is medical terminology, which includes lessons in medical abbreviations. Although we are taught to use abbreviations, it may not always be prudent to do so. Using incorrect or unapproved abbreviations can lead to misinformation or misinterpretation of the patient’s medical record. When this occurs, significant errors and risks to patient safety occur.
As a nurse, I have learned that it is best to limit the use of abbreviations when documenting nursing progress notes. Although some abbreviations are commonly used and may be approved by your facility, the less you use them, the fewer chances of there being mistakes in the chart. Therefore, unless management requests you to use them, avoid using abbreviations and acronyms altogether.
Many healthcare facilities now utilize electronic health records to document patient care. However, some remain that use hand-written documentation. One of my biggest pet peeves as a nursing instructor and as a nurse working with other healthcare professionals is finding nurse's notes that are sloppily written. It is crucial to realize and remember that the patient's chart is a legal document. Anyone who picks the chart up to read it should be able to read what you write without trying to decipher through shorthand, jargon, and poor penmanship.
The best way to avoid writing a sloppy nursing progress note is to take your time. Find a place with little distractions and focus on the task at hand. Pay attention to the spelling of words to ensure you do not have errors in your notes. If you do make a mistake, mark one line through the error, initial it, then write the correct entry.
It is understandable that your day at work may be busy. Many nurses care for several patients each day. When your patient load is heavy or unexpected events occur, it can be easy to put off documenting until things slow down. Unfortunately, if the time between your patient encounter and when you create your note is too long, you may end up forgetting important details that need to be mentioned.
The ideal situation would be to provide patient care and immediately document in your nursing progress notes. However, when that is not possible, at least take a few moments to jot down important information that needs to be documented so you do not forget to include it in your notes. I always carry a small memo pad in my pocket to write quick notes on. If you use a tablet or other electronic device provided by the hospital, there may be a way to enter short details and then return to complete the progress note using the details you saved.
I cannot tell you how many times I have heard nurses say they were unaware of something that happened with a patient in the shift before them because the nurse working off did not mention the event during the end-of-shift report. Granted, end-of-shift reporting is essential and gives nurses the opportunity to discuss important patient details. Can you imagine how long a report would take if every nurse reported every detail about each patient in the end-of-shift meeting? If that happened, it would be difficult to make it to the floor to provide care to patients.
Although it is the responsibility of the nurse leaving work to report any significant information or changes, it is your responsibility to read nursing progress notes from previous shifts to make sure nothing is missed. For example, suppose Nurse Smith reported to you in the end-of-shift report that Mr. Jones says his headache is finally gone, but she did not mention she administered pain medication to help relieve the pain. If you do not read the chart and Mr. Jones complains to you of a headache, you may administer more pain medication before it is due, which results in a medication error and patient safety issue. Always, always, always read the notes from previous nurses!
You can spend hours on end with your patients and provide all the care you can imagine, but if you do not document your actions, in the eyes of the law, you did not do it. Failing to document patient care can open the door to serious problems, especially if the patient complains about care or, worse, seeks legal counsel because they believe they were injured by care or were neglected.
Whether you perform wound care for a Stage IV decubitus ulcer or put a band-aid over a small nick in the skin, you must document all interventions. Carefully document the details of each nursing intervention, including any supplies you use and the patient's response to care. Proper documentation can mean the difference between keeping your nursing license and job or losing your job and license because of an inability to prove you provided care.
Documenting patient care is an essential part of nursing. There are many types of nursing documentation. The type of documentation you use will likely be determined by the care your patient needs and your facility’s guidelines. One of the most common types of documentation is a nursing progress note. In this article, I shared 5 perfect nursing progress note examples + how to write to answer the question, “What is a nursing progress note?”
Any licensed nurse can write a nursing progress note.
Some nurses write nursing progress notes at the end of their shift. Others write the notes at each patient encounter. The facility where you work will have guidelines for when to write nursing progress notes and how often.
Not all facilities require nurses to write progress notes each shift. Ideally, nursing progress notes should be written when there is a change in the patient’s status, a change in the plan of care, or to document the patient’s response to care.
It is hard to say what the ideal length of a nursing progress note should be. The length of notes varies, sometimes significantly, based on the patient’s diagnosis, changes in status, response to treatment, or changes in care.
Every part of the nursing progress note is important. If you follow the correct procedure for completing your progress notes, you should include subjective and objective data, a plan of care, a record of interventions, and patient responses.
• Documentation must be centered around the nursing assessment and nursing interventions that should occur.
• The note should document previous conditions and responses to treatments as well as changes in the patient’s health condition and any new interventions to be implemented.
• The nursing progress note must reflect the extent of care needed, such as continuous care, the patient’s needs, and any interventions initiated to provide that care.
• HIPPA Privacy Rules must always be upheld.
• The nursing progress note must be clear, legible, and contain accurate information.
Although some facilities may allow the use of abbreviations in nursing progress notes, it is a practice that is strongly discouraged to help reduce the risk of errors or patient safety events.
The tense you use to write a nursing progress note depends on when you write the note. For instance, if you prepare the note at the patient's bedside as care is done, you may chart what you see and do in the present tense. However, if you prepare your progress note later in your shift, you should document it using the past tense.
Nursing progress notes that are not completed using an electronic health record may be handwritten or printed. The rule of thumb is to use the form of writing that is most legible. If your printed handwriting is clearer than cursive, print the note. If you write in cursive more clearly, use cursive writing.
All nursing progress notes should be signed with your signature and title.
Forgetting to write a nursing progress note at the time it should have been written can lead to negative consequences for you as the nurse, your place of employment, and the patients for whom you provide care. Failure to write the note at the appropriate time does not mean you should not write the note. If you forget to write a note and have already left your facility, call your supervisor immediately and report the issue and any pertinent information that should have been documented. Then, as soon as you return to work, you should create a late-entry nursing progress note.
Yes, nursing students can write a nursing progress note. The student should sign the note as any nurse would, with their signature and title. Some facilities may require a staff nurse or nursing instructor to sign behind the nursing student.
Darby Faubion, RN, BSN, MBA
Darby Faubion is a nurse and Allied Health educator with over twenty years of experience. She has assisted in developing curriculum for nursing programs and has instructed students at both community college and university levels. Because of her love of nursing education, Darby became a test-taking strategist and NCLEX prep coach and assists nursing graduates across the United States who are preparing to take the National Council Licensure Examination (NCLEX).
