- Progress note
- What is it?
- Used to determine patient’s medical status
- Care & Treatments
- Chronological report
- Documents nursing actions and observations throughout shift
- Includes responses, changes and issues
- Used to determine patient’s medical status
- Why write one?
- Legal evidence
- Quality assurance
- Nursing Process
- Physical assessment
- Patient interview
- NANDA nursing diagnosis
- Prioritize care
- Set goals/outcomes
- Determine outcomes
- Determine effectiveness of interventions
- Make changes as needed
- What is it?
- Components of a Progress note
- What to include
- Patient condition
- Lab values
- Diagnostic procedures
- Medications & Treatments
- New orders
- Other interventions
- Patient response to interventions
- Follow ups
- Care & teaching provided
- Complaints/other issues during care
- What to include
- Types of Progress notes
- Source oriented
- Separate notes for each team member
- Problem oriented
- SOAP note
- Most popular
- What the patient says
- Chief complaint
- Why is the patient here?
- History of present illness
- Onset of symptoms
- Location of symptoms
- Duration of symptoms
- Character of symptoms
- Alleviating/aggravating factors
- What relieves or makes it worse?
- Does it stay in one place or move?
- Temporal pattern
- Is it worse at a certain time of day?
- Scale of 1-10
- Things we observe
- Physical assessment
- PIE note
- Uses nursing diagnosis
- Nursing diagnosis
- Care/treatment provided
- Did the intervention work?
- SOAP note
- Highlights specific problem, condition changes, concerns or events
- Rules of writing a progress note
- Be consistent
- Be concise
- Be timely
- Never chart in advance
- Always notate date and time written
- Use standard abbreviations
- Familiar to other medical personnel
- Approved by agency/facility
- Remain objective
- Avoid opinion/personal feelings
- Note all communication
- Sign all notes with credentials
- Hand-written notes
- Write legibly
- Use black ink
- No white out
- One strikethrough only
- Sign/initial error
- Date and time with initials
- Source oriented
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
Today we’re going to be talking about how to write a nursing progress note.
In this lesson, we will cover the types of progress notes you can write, what information actually goes into a progress note, and what you absolutely must know before you begin writing one.
Let’s start by addressing what a progress note is. Nursing progress notes document our patient’s medical status. We document any assessments, care and treatments we’ve performed on our shift, and the patient’s progress and response to those actions. The goal of the progress note is to write a chronological narrative of the shift including any issues you may have come across. For instance, you can write a note after you complete your initial assessment. It may look a little something like this: (date/time: Physical assessment completed. VS WNL. Pt A&Ox3, no complaints of pain at this time. RN signature). If there’s anything abnormal about your assessment, it would go here as well along with any interventions you may have had. Remember that nursing progress notes are legal documents and can be used in court proceedings, for insurance reimbursement and for quality assurance purposes.
The nursing process is something that will never go away. It shapes the way we work as nurses! With that said, it’s important to show you how it affects the way we write our progress notes as well. So our assessment is anything we found in the physical assessment or in the patient interview. You’ll want to include that information in your note, particularly for those findings that aren’t normal. NANDA diagnoses are used dependent on your facility policy, but you may want to use it to determine what your central focus is for your patient. It will help shape your plan of care. As I’m mentioning plan, this is where we are prioritizing our care. This is why I say you can use the NANDA diagnosis. In the process of prioritizing, you should be setting goals for your patient to achieve on the short term. Maybe you want them to achieve something before the end of your shift, or before discharge. Interventions are the implement stage of the process. These are those treatments and any other care we are providing during the shift. Finally, we have the evaluate stage. This is where we are looking for the response to interventions and making changes to the plan as needed. Why did I bring this up? We all know ADPIE at this point but what you may not know is you can always refer back to it if you get stuck on what to write in your notes.
What do we put in a progress note? Remember, we are creating a narrative description of what happened with the patient during the shift. So we want to include the patient’s condition and any abnormal lab values or diagnostic results. Any tests that the patient had completed or ordered should also be included even if we don’t have the results back. Medications and treatments, as well as the patient’s response to them are very important to include. This includes any patient concerns, complaints or other issues as well as the care or any teaching we have provided during the course of the shift. We want to know if they tolerated the treatment or if a change has been made or is warranted. Were there any new med orders made? We also talk about any follow up care or consults that may be required. When you hear it in a list like this it sounds like a lot. But think about what you’re expected to do on your shift as a nurse. The most important take-away here is that you want to document the things that happened, because if you don’t, it didn’t.
There’s a lot of different ways to write a progress note, however, we will discuss the ones you may see most frequently. These are the SOAP note, the PIE note, and the DAR note. Let’s explore each of these individually.
SOAP notes are the most popular progress note for nurses. They fall into the category of problem oriented notes, which means we are focused on the reason for seeing the patient. It lays out exactly what we need to include. Subjective information is what comes from the patient. We take this information in the History & Physical most often and it includes not only why they are here with us, but also the details of their symptoms. Objective information is what we observe, usually from the physical assessment we perform. Bear in mind there can be times where S and O don’t necessarily add up, but make note of it all anyway. Then we have the assessment and the plan. Again, we take that from the nursing process. Find the problem and make a plan to fix it. So let’s say we have a patient who just had abdominal surgery 2 days ago. The SOAP note may look something like this: S – Pt reports pain and itching around surgical site. Pt states the pain is 4/10 and throbbing. O – Pt A&Ox3, calm and cooperative. VS WNL. No edema to extremities. Lungs clear. OOB to chair with assistance. Positive bowel sounds in all 4 quadrants. Redness and swelling around surgical site. Tenderness noted in LUQ. No drainage or bleeding present. Dressing CDI. Pain medication given per order for mild to moderate pain. Call light in reach. A – Pt pain level decreased to 2/10 after pain medication. Pt has some SOB after ambulation to chair and c/o mild fatigue. P – Will continue to assist with activity as tolerated. Continue pain medications, skin care and dressing changes as ordered. Assess surgical site throughout shift. Report any other issues to physician.
PIE notes are another problem oriented note, but these rely on the use of the nursing diagnosis to identify and document the problem, discuss the care or treatment provided, and then whether or not the intervention actually worked. PIE notes are a little more clear cut and to the point, but don’t allow for as much detail as SOAP notes. Let’s use the same patient we just discussed. The PIE note may look like this: P – Acute pain r/t surgery as evidenced by reports of pain 4/10. I – Administered pain medication as ordered for mild to moderate pain. Assistance provided for OOB activity. Call light placed in reach. E – Pain decreased to 2/10. Pt uses call light when in need of assistance. We said the same thing as we did in the SOAP note, just more concise and we focused on a central issue, in this case, the patient’s pain. If there are other issues, you can write on those as well.
DAR notes are in a different category than SOAP and PIE notes. These notes are called focus notes, which highlight a specific problem, condition changes, concerns or events. When you think of it that way, it’s easy to determine what each piece is for, but I’ll explain anyway. Our data comes from the assessment findings. So this is likely both subjective and objective information if you think of it in terms of SOAP notes. Action and response are exactly that. What did we do to address the problem we’ve identified, and did it work. Let’s revisit our post op patient again. The DAR note may be this: D – Pt is 2 days post op abdominal surgery. Pt c/o pain 4/10 around surgical site. Some redness, swelling and tenderness noted at the site. A – Tylenol 325mg 2 tabs PO administered as ordered for mild to moderate pain. R – Pt reports pain decreased to 2/10 after medication administration.
So we’ve arrived at the rules for writing progress notes. Remember, we said earlier that progress notes are a legal document. If you are ever called to testify in court, your notes can be used as evidence so you want to be sure that you are consistent, concise and timely with your notes. Never write notes in advance. Anything can happen and more importantly, if you’re writing ahead of time, do you really have true knowledge of the situation? We love to use short-hand in the medical field. It’s okay to do this, just be mindful that the abbreviations you use are standard and approved before doing so. Make sure that what you are using is familiar to everyone reading. No one wants to have to track you down to clarify what you meant. Include any and all communication you’ve had regarding your patient and ensure that you use quotations so it is clear that what you are writing was a statement made by the person you are referring to. This includes family members, visitors, and medical personnel. This is important, because once it’s written down, it can’t be denied or changed. Above all else, you earned your credentials. You worked hard for them. So make sure you are using them when you sign off on your notes. It’s a standard you will get used to.
A final note for those who still create hand-written notes. Make sure you write legibly in black ink only. This is a legal requirement, I’ve always been told. Also correcting errors is a really big thing for legal reasons. We all make mistakes and it’s okay to as long as you find it and correct it. When you do make an error, know that white out is not permitted. You should put one line through the error, and initial with date and time.
Let’s talk some key points. Remember progress notes are legal documents. They can be used in court or for insurance to pay your facility. Be mindful of what you write. If you ever get stuck on what to include in your progress notes, it’s okay. You can always come back home to the nursing process! A goal in writing progress notes is to stay objective! It is not the place to air your grievances and should stay judgment free. Document ONLY the facts! Most important, always remember, If it’s not documented, it didn’t happen. Make sure you hit everything you want the reader to know.
That’s all! We love you guys! Go out and be your best self today! And as always, Happy Nursing!