How to Write Nursing Progress Notes - With Examples
Why Writing Good Nursing Progress Notes Is Essential
Nursing progress notes are legal records of the medical care a patient receives, along with details of the patient’s welfare and recovery.
Well-written nursing progress notes are a vital tool for improving the quality of care. Nurses can review past progress notes for essential information about the patients’ condition and current treatment.
Progress notes also provide a record in case there are any incidents. It’s much easier for nurses to remember the details of what happened during their shift, as opposed to when a complaint is made.
Plus, as long as the patient consents, progress notes can be shared with family members and friends. In this way, well-written progress notes help a patient’s loved ones feel involved and provide additional support.
How to Write Nursing Progress Notes: A Cheat Sheet
Progress notes can be written during the shift, as nurses notice important information, or at the very end of the shift. Although they do not need to be a complete record of the shift, they should include certain information:
Date and time
Clinical assessment, e.g. vital signs, pain levels, test results
Details of any incidents
Changes in behaviour, well-being or emotional state
Changes in the care provided
Instructions for further care
You can use the ISBAR mnemonic to help structure progress notes: identify (who the nurse and patient are), situation, background, assessment and recommendation. ISBAR is often recommended for walk-in patients, but it can be used in any medical setting.
Alternatively, some nursing professionals prefer the SOAPIE mnemonic: subjective (unmeasurable symptoms, often what the patient reports), objective (your assessment of the patient’s condition, e.g. temperature), analysis, plan (proposed treatment), implementation and evaluation (of the impact of the implementation).
Both ISBAR and SOAPIE can help you write effective progress notes. Just make sure that whatever structure you use, you’re including all the important details.
4 Tips on How to Write Nursing Progress Notes Well
The key to good progress notes is remembering that you’re not just recording information: you’re also communicating it. Somebody will read your progress notes and use them to make decisions about patient care.
As such, good nursing progress notes are easy to read. They are clear, precise and objective. To help you achieve this, put these tips into action:
Use the Active Voice
The active voice specifies who does the action. The passive voice doesn’t. For example:
Active: I administered 15 ml of the medication.
Passive: 15 ml of the medication was administered.
A good test is that if you can add “by the patient” to the end of the sentence, it’s passive voice.
Passive voice is more formal, but it can be confusing and leave important details out. When recording actions taken, use the active voice instead.
To keep your nursing progress notes precise, be as specific as possible. Quantify where you can, and use objective descriptions where you can’t. For example, “the patient described their pain as a 7 out of 10” is better than “the patient reported high pain levels”.
Include the Important Information — And Nothing Else
Nursing progress notes strike a good balance between being detailed and concise. You want to include all the relevant information, so make sure to use our nursing progress notes checklist above.
However, you don’t want to include unnecessary information that will make the progress notes harder to scan. As you write your progress notes, think about why you’re including details. Are they part of a clinical analysis, incident or change in conditions or care? If not, are they really necessary?
Make your sentences concise, too. Cutting wordy phrases will help the important information stand out to readers. For example, you could change “I asked the patient if they would let me take their temperature three times, but every time I did, they said they didn’t want me to do it” to “I tried to take the patient’s temperature three times, but the patient refused each time.”
Use Professional, Matter-of-Fact Language
Your progress notes might be read by fellow nurses, the patient and even the patient’s loved ones. To keep it appropriate for all readers, make sure your tone is professional, matter-of-fact and easy for laypeople to understand.
A Good Nursing Progress Notes Example
There’s nothing like reading an example to help you grasp a concept, so let’s take a look at a sample nurse’s progress note:
08.07.2022 — 10:30 am
Patient: Anne Example
The patient reported dizzy spells lasting up to 10 minutes once or twice a day over the last week. I took her blood pressure at 10:20 am, and it was 110/70. I took a blood sample to test her iron and sugar levels. I asked the patient to keep a food diary and record dizzy spells for the next week.
What makes this progress note so good? It uses quantifiable data and matter-of-fact language to describe the situation, assessment and proposed actions. It’s concise and easy to read yet includes all the important details.
Nursing Progress Notes Made Simple
Nursing progress notes are an essential tool for improving patients’ welfare and helping your organisation or healthcare centre operate as smoothly as possible.
Here at ShiftCare, we believe the right systems can help you provide better care. That’s why our app allows nurses to view and add progress notes on the go. Our speak-to-text feature makes recording accurate progress notes easy, plus you can create customised progress notes templates to ensure staff record all the essential information.
Discover how ShiftCare can help your team create better progress notes with a free trial.