All nursing documentation needs to be accurate, detailed and clear. This is especially important for nursing progress notes, which serve as a communication channel between carers and support workers. 

Why Do We Keep Nursing Records and Progress Notes?

Progress notes perform several important roles in nursing care. They are legal documents as well as medical records. This means that in addition to forming part of your patient’s nursing record, they provide proof of service delivery and can be used as evidence in investigations and inquiries.

Proper documentation also improves the quality of patient care by facilitating communication between team members. When nurses have access to the latest information about a patient’s health and care, they can make more informed decisions. Good nursing documentation supports the nursing process. 

Well-written nursing documentation also facilitates patient planning. It can help home care providers analyse a client’s progress, adjust care plans and set relevant goals.

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.

What to Include in Nursing Progress Notes

Nursing documentation does not need to include every single thing that happens on a shift. In fact, too much information is almost as bad as too little information. Nurses must be able to quickly read the progress notes from the last shift and identify the relevant information. They cannot do this if there are too many irrelevant details.

However, there are some details that should always be included in nursing progress notes. These include:

• The date and time

• The patient’s name

• The nurse’s name

• Clinical assessments; e.g. vital signs, blood sugar levels, pain levels 

• Medication 

• Any incidents

• Changes in the patient’s well-being or behaviour

• Changes in the patient’s care 

• Instructions for further care

How to Write Excellent Nursing Progress Notes

You can create better nursing progress notes by following these guidelines:

1. Use a Template

   Nursing progress notes templates will help you to produce more complete documentation. You can also create different templates for patients with more specific needs. 

2. Write Your Progress Notes Straight Away

   The quicker you fill in your progress notes, the more likely you are to remember all the important details. Some nurses like to regularly add details to their progress notes throughout the client visit, while others prefer to fill them in immediately afterwards. 

3. Provide Details

   The more relevant details you can provide, the more useful your records will be. For example, if a patient’s in pain, you should specify pain levels, location and type. 

4. Be Concise

   Concise writing is more reader-friendly. Remember, you’re writing these records to help other nurses.

5. Double-Check Your Notes Are Accurate

   Re-read your notes to check you haven’t made a typo or misremembered any details.

6. Use Professional and Objective Language

   Your progress notes are legal documents, and they may also be shared with the clients or their loved ones. It’s important to get your tone right. Focus on what happened instead of your interpretation of the situation. For example, instead of saying “the client was difficult”, say “the client refused to take their medication at 13:05, 13:20 and 13:30”.

7. Adopt the Active Voice

   Here’s an example of the active and passive voice:
   

   Active: I changed the patient’s bandage.

   Passive: The patient’s bandage was changed.

When we write formally, we often adopt a passive voice. However, this can obscure important information, such as who took the action. Always use the active voice. 

Looking for more insights on writing good nursing documentation? We’ve written a step-by-step guide to writing progress notes that are actually helpful, plus we’ve published nursing progress notes examples that will help your team create good records.

Support Your Staff in Writing Better Nursing Documentation

Quality nursing documentation can drastically improve patient care. What’s more, it can support your team and help your business meet its legal obligations.

There’s a lot to consider when writing nursing progress notes, but it doesn’t have to be a difficult or time-consuming process. The right tools will streamline how your team writes nursing progress notes. Your staff will be able to create accurate and detailed progress notes in fewer than five minutes.

ShiftCare’s care management software will support your care provider business with client, staff and documentation management. It has a robust set of progress notes features designed around the needs of the healthcare field. These include customisable templates, secure cloud-based storage, access controls and instant sharing with appropriate team members.

Voice-to-text features will allow your staff to complete progress notes on the go. They’ll be able to upload progress notes while the details are fresh in their memory, which can lead to more accurate documentation.

Plus, you can use the ShiftCare Connect feature to share relevant progress notes with clients and their loved ones.

Discover how software can help your team write better progress notes. Try ShiftCare for free.