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. Disability providers have their own requirements, covered in our guide to NDIS progress notes. 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
• Patient’s name
• Nurse’s name
• 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.

 

Working from a set structure makes this quicker. The nursing progress notes template lays the same fields out in order so nothing gets left off at the end of a shift.

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:

 

1. 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.

 

2. Be Specific

 

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”.

 

3. 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.”

 

4. 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.

 

How Nursing Progress Notes Improve Patient Safety

 

In the healthcare field, patient safety is critical. Effective nursing documentation can increase safety levels by reducing the risk of errors, improving the quality of care and support provided, and enabling more personalised nursing care.

 

Staff are less likely to make mistakes when they are supported by accurate documentation. Whether it’s a temperature reading or a description of a client’s pain levels, correct data will reduce the possibility of nurses overlooking important symptoms or misdiagnosing a client’s condition. This is particularly important when it comes to medication usage.

 

Proper documentation can also lead to more empathetic and human-centric services. Nurses will have better insights into the patient’s well-being, emotional state and needs. As such, they can tailor their support. This is especially helpful for patients with reduced communication skills, Alzheimer’s and other conditions that may prevent them from advocating for themselves.

 

Speed matters, but so does whether the record stands up later. For what makes a note defensible under audit or complaint, read how to write care records that hold up.

How Long Should It Take to Write Nursing Progress Notes?

 

Writing progress notes doesn’t have to be time-consuming. In fact, an excellent progress note can be written in five minutes or less.

 

However, if your staff members are inexperienced, not given the support and training they need, or struggling with outdated technology, it can easily take twenty minutes or longer to write progress notes. The less confident your team members are in writing progress notes, the more time they’ll spend second-guessing themselves. An even more pressing issue is that these staff members are unlikely to write helpful progress notes that will support their colleagues.

 

This is why it’s important to streamline the process of writing progress notes and provide sufficient support for your team. Let’s explore how you can do that.

 

How to Write Nursing Progress Notes Faster

 

While good progress notes should be easy to read, they aren’t always easy to write. Optimising the process of writing progress notes will help you ensure quality and the inclusion of specific details. Plus, you’ll be able to better support your team in efficiently writing them.

 

1. Use a Progress Note Template

 

We’ve created a detailed guide to writing progress notes that are actually helpful, but the easiest way you can support your team in writing excellent progress notes is by crafting templates.

 

Structured templates for progress notes will ensure their effectiveness. Your documentation management software should allow you to set and edit template headers. Be as specific as possible when creating them to help guide your staff through the process, whether it’s their first shift or their thousandth.

 

Our nursing progress notes cheat sheet will help you get started in crafting a progress notes template. However, clients with different health conditions and care plans will typically need different information in their progress notes. As such, it may be worth building multiple templates for progress notes.

 

2. Create Progress Note Guidelines

 

A progress notes template will ensure your employees include all the vital information. However, you should also create guidelines as part of your SOP documentation.

 

These guidelines should break down how to write progress notes, including the importance of:

 

• Being concise
• Making objective statements, e.g. “The patient couldn’t remember what day it was, and only recognised her neighbour after prompting” instead of “The patient seemed confused”
• Including quantitative data where possible, e.g. “The patient had a temperature of 38°C” instead of “The patient had a fever”
• Using an active voice that explains who took each action, e.g. “I administered the medicine” instead of “Medicine was administered”

 

Make sure to share this documentation with your team and store it in an accessible location.

 

3. Train Your Staff

 

Your staff will find writing progress notes easier if you train them on it, and in particular, on using the templates and guidelines. For increased effectiveness, you should also regularly give both positive and constructive feedback. This will help reinforce the information provided during training.

 

4. Fill Out Progress Notes on Shift

 

Ask your employees to record progress notes as quickly as possible. The sooner they add their progress notes, the more accurate and detailed they’ll be. For example, for in-home care, make sure progress notes are completed while still in the client’s home.

 

5. Use Modern Tools

 

Not all staff members will feel comfortable typing detailed progress notes from their phones. Speak-to-text features can enable your team to add progress notes while on the go, without sacrificing quality or important information. Don’t forget to double-check that your templates are compatible with these features.

 

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.

 

Get the Progress Notes Template Your Team Will Actually Fill In

Nursing notes fail review for the same reasons every time: missing observations, no record of how the patient responded, and entries too vague to act on.

Our free progress notes template gives every worker the same structure to write against. Download it, adapt the headings to your service, and use it from the next shift.

See how progress notes work in ShiftCare if you would rather capture them in the app than on paper.

What should be in a nursing progress note?

 

Include the date, time, patient condition, interventions, responses, and any changes in status. This ensures a complete and accurate record.

 

How can I make my progress notes clear?

 

Use concise, objective language, avoid jargon, and be specific about observations and actions. Follow a structured format like SOAP (Subjective, Objective, Assessment, Plan).

 

Why are nursing progress notes important?

 

They document patient care, aid communication among healthcare team members, and provide legal records of care provided.