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 their 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 are important for informing 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.

A good nursing note involves verifying the correct patient's chart, accurately recounting the patient's response, and documenting the activities performed or witnessed, such as when a patient reports pain. Accurate and timely documentation is crucial for effective communication among healthcare providers, ensuring patient safety, and meeting regulatory and legal requirements.

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

How to use this Progress Notes for Nursing Template

It's simple to get started using this PDF progress note template in your nursing practice, but to ensure you're getting the most out of your template, follow the steps below.

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

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 as 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 for 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.

Progress Notes for Nursing Template example (sample)

If you want to see what this nursing notes example looks like when it's completed, we have created one to illustrate what it can look like when it's all filled in. This template serves as a good nursing note example to guide nurses in their documentation.

Download this Progress Notes for Nursing Template example here:

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. Its structure is 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.

This 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 nurses?

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. In this one, there are no such redundancies.

Keeps 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 puts your entry 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.

Why use Carepatron for nursing notes?

Your progress notes are important medical records that include sensitive patient information legally required to be stored securely. Having one reliable, secure place to store your notes is a big help in meeting your legal obligations. Carepatron offers a digitally encrypted, HIPAA-compliant method to store your progress notes and all the other documents making up your patient's medical record. In addition to being secure, Carepatron is easily accessible on mobile or desktop for all your patient care team members. 

Beyond storing your progress notes, you can create, access, edit, and share them with others on your team or your patients through the patient portal.

Carepatron also offers AI-powered speech-to-text medical dictation software compatible with all our clinical templates. It provides a suite of helpful practice management features, such as appointment scheduling, coding, billing management, and video call functionality.

Optimize patient care and write nursing notes accurately and conveniently. Sign up for Carepatron today!

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