Progress Notes For Nursing Template

What is a Progress Notes for Nursing Template?

Progress notes, specifically nursing notes, take up a large chunk of a nurse's day, regardless of specialty or workplace. As such, progress note-taking is a great skill to develop that is guaranteed to benefit your nursing career regardless of your future direction.

Progress Notes for Nursing Templates inform clinical decision-making and medical record-keeping. Every nurse has a different note-taking style that works best for them. When designing a template for nurses to take progress notes, we knew we had to keep it simple but add a few useful features to save time.

Good nursing notes involve verifying the correct patient's chart, accurately recounting what the patient states, and documenting the activities performed or witnessed, such as when a patient reports pain. Accurate and timely documentation of objective data is crucial for effective communication among healthcare providers, ensuring patient safety, and meeting regulatory and legal requirements.

How to use this Progress Notes for Nursing Template

It's simple to use this PDF progress note template as a communication tool in your nursing practice, but follow the steps below to ensure you're getting the most out of it.

Step 1: Download the PDF

The first step to start using this Progress Notes for Nursing Template in your practice is to download the PDF using the link on this page. Once you have downloaded the free PDF, click within the interactive text boxes to start typing. Alternatively, you can print this nursing note PDF and fill it in by hand if that's more your thing.

Step 2: Add the date and time of your note on patient's response

Every nursing note needs to include the date and time of your interaction to build a solid timeline for your patient and medical record-keeping purposes. Add the date and time in the Date/Time column before you start writing the note so you don't forget it.

Step 3: Add your progress note

We have left the progress note section blank for you to use your preferred note-taking method. With our template, you can use whichever method you prefer for taking patient reports—you can use Subjective, Objective, Assessment, and Plan (SOAP), Focus, Data, Action, and Response (F-DAR), or Problem, Intervention, and Evaluation (PIE) methods.

Step 4: Add your signature or initials

Once you have written your progress note, add your signature or initials in the initials column. This is an important step for accountability and meeting the legal obligations regarding your patient's medical record keeping. 

Step 5: Save your changes securely

The last step is to save your progress note securely—if you use our app, secure storage is a given. If you use this template digitally, ensure that healthcare professionals accessing it understand how to use it without overwriting each other's hard work.

Who can use this nursing progress notes template?

This template is designed for registered nurses (RNs) who routinely take periodic progress notes on their patients during assessment and treatment. It's designed for concise progress notes (not a whole medical history!) set chronologically. The concise nature of these progress notes makes them best for use with patients in an in-patient setting, where you may look after several patients on the ward at once.

As such, this template can be a great organizational tool for documenting interventions, treatments, and patient care adjustments, facilitating communication between the healthcare team and giving medications—these are only a few examples.

This good nursing note template can aid the progress note-taking process for nurses working in:

• Perioperative nursing
• Critical care
• Oncology
• Pediatrics
• Hematology
• Occupational health
• Hospice care
• Cardiac care
• Geriatrics

It's essential to keep in mind that this template is also available for other nurses who may not fall within the registered nurse discipline. These include nurse assistants, trainees, or student nurses still developing their patient progress note-taking skills.

Why is this nursing documentation template useful for healthcare professionals?

Writing nursing notes is crucial for documenting patient reports, including changes in vital signs, and ensuring patient education. It also helps healthcare providers by reinforcing information when reviewing a patient's medical history. This template was designed with nurses in mind to save them time and make their busy lives a little bit easier. Some of the useful points about using this template in your nursing practice are included below:

Allows you to use your preferred style

We have kept this nursing progress notes template simple enough for you to use whichever note-taking style you prefer. Many other templates add extra headings you will never use or sections that don't apply to your patient's care. This one does not have such redundancies.

Keep your notes organized

Our table format keeps your progress notes in a readable, chronological order. Print multiple copies to keep the progress notes going beyond the first page.

Provides evidence of your decision-making process

Our progress notes template lets you document in the context of your patient's complete progress notes from all other nurses in their care team. As such, our completed progress notes template provides excellent evidence of your decision-making skills and teamwork for any continuing professional development (CPD) you must undertake.

Our nursing notes template is a free PDF resource for keeping track of patient progress notes in a pre-formatted structure with handy columns for the date, time, and nurse's signature or initials. Download it for free today!