Nurses under any hospital operational plan or in any other institution are also bound to do their deliverables such as reports and other documents necessary for the improvement of their productivity skills and for the welfare of their patients. One of the documents that they need to accomplish is their nursing progress notes that are created according to what department and institution they are working for. Examples of nursing progress notes are Psychiatric Nursing Progress Note, Audit Tool Nursing Progress Note, Ambulance Nursing Progress Note, among others. These are vital parts of their job description since these reports are used for immediate and future purposes.
10+ Nursing Progress Note Samples
1. Nursing Home Chart Progress Note
2. Ambulance Nursing Progress Note
3. Nursing Documentation Progress Notes
4. Psychiatric Nursing Progress Note
5. Audit Tool Nursing Progress Note
6. Patient Nursing Progress Note
7. Health Care Nursing Progress Note
8. Nursing Patient Care Checklist Progress Note
9. Volunteer Nursing Progress Note
10. Clinical Nursing Progress Note
11. Narrative Nursing Progress Note
Tips in Writing a Nursing Progress Note
With all the formats available to make a formal progress note among nurses, what qualities are needed for it to be effective and to meet a satisfying employee performance goal? To help you with your own nursing progress note, you can download our free sample templates. Keep reading.
- Write the patient’s story
Upon receiving the patient for medical consultation or to ask them about their medical issues, they are basically telling the story leading to the events of what causes their pain or illness. Having a job description as a nurse or a medical professional, you are there to listen to their hurt and provide immediate assistance such as comforting them or encouraging them that what they are suffering is treatable and you can help them achieve that in your own ways and abilities.
While listening to them, it would help you to formulate and construct your story if you ask relevant questions pertaining to their experiences in life-related to the situation they are in, and also those questions that have something to do with their illness or injury. After you gathered the needed information, you can use them in your progress note and of course should be written in a clear and logical manner so that.
- Be careful in putting a diagnosis
One rule for medical professionals to consider what initial diagnosis they will put on their note as it will be the basis of further tests that the client will undergo. This will also be the basis on which a therapy progress note is anchored if therapy is necessary as part of their treatment. For example, if the initial diagnosis of a Vitamin B12-deficient person is mistaken for “depression”, that will tag that person as someone who is depressed all throughout the journey of his treatment plan. Instead of just simply giving them vitamins and food supplements, the resources of both the hospital and the client are wasted in order to treat a misdiagnosed condition.
If you’re not sure about the exact diagnosis, your uncertainty must also be indicated in your note and must be clear enough for the next medical person to check your initial guess if it’s true or not. Modifiers like “seems” and “possibly” are likely to be used to indicate uncertainty in your note. You can also use our free sample treatment plan templates as a guide according to the specific kind of treatment you are looking to make.
- Write specific plans and avoid being vague
When writing the plans for the treatment of the client, it should be done in a clear and specific way. Thus, generalizations should be avoided in your progress note and putting into words the steps or picturing out the real scenarios of what the clients should do to effectively convey the treatment plan. For example, instead of writing, “Plan to lose weight”, you can write, “Reduce sugar intake such as soda and sweets for a week”. You are also like writing a research report in which the details are outlined properly and according to their importance.
What is a diagnostic error?
It is the erroneous result of diagnosis among medical professionals that may lead to serious repercussions towards a patient’s health.
What is a referral?
Referral in medicine means that the patient is/will be transferred to the care of another clinician that is done by their current clinician in order to secure their health and welfare.
What does it mean by adaptive immunity?
The ability of the human body to develop immunity against germs after being exposed to them.
Needless to say, the importance of a clearly written and logical nursing progress note not only indicates a narrative of the condition of a client but also serves as a basis if the current treatment is effective or not to cure the patient’s illness or condition. It should be done in a brief and correct manner as the wrong diagnosis and incorrect choice of words to use and illogical construction may lead to grave consequences to the lives of the patients.
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