Streamlining the Process of Writing Nursing Progress Notes in 5 Key Steps
A more efficient progress notes process means more time per shift spent on patient care and less stress for your nurses.
Good Progress Notes Are the Key to Quality Care
Effective progress notes are objective, concise and detailed. They include all the key details other nurses need to know, without any fluff. And in doing so, they set your team up for success.
Progress notes serve numerous purposes. They are essential documentation, providing proof of service delivery, a legal record and evidence in case of incidents.
They also make it easy to track patients’ progress over the short and long term alike. They demonstrate whether a client’s condition is improving or deteriorating after an injury or illness. Where medical attention is required, the information from the progress notes can be used by healthcare staff to reach the patient’s diagnosis. You can also use them for plan reviews and goal-setting.
On a day-to-day level, they also make sharing information much easier. With a client portal, you can automate the sharing of important progress notes with patients and their family members.
Additionally, with cloud-based progress notes systems, your team can instantly share the latest client information. This will help your frontline staff make more informed care decisions and provide empathetic, personalised and high-quality services. Well-written progress notes enable the next shift to go smoothly.
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However, if your staff members are inexperienced, not given the support and training they need, or struggling with outdated technology, it can easily take twenty minutes or longer to write progress notes.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 Streamline Writing Progress Notes
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:
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.
Tools That Make Progress Notes Simple
Progress notes are an essential nursing tool. However, they can only be useful when they’re written well.
ShiftCare’s care management software will help your team write effective progress notes and track the information that really matters. With speak-to-text features, it’s easy for staff members to update progress notes on the go, when the information is still fresh in their minds. You can set up a wide range of progress note templates so that every team has the support they need. And with instant sharing and rigorous privacy controls, you can ensure that everyone has access to the information they need (and nothing more).
Plus, ShiftCare comes with an extensive range of features for care and disability support providers, including a robust scheduler, documentation management, NDIS integrations, client funds management and accounting integrations.
Discover how care management software can support your team by trying ShiftCare for free.