Get Nursing Progress Note Template

Completing the Nursing Progress Note Template online is crucial for maintaining accurate patient records. This guide will provide you with step-by-step instructions to ensure you fill out the form correctly and effectively.

Follow the steps to fill out the Nursing Progress Note Template.

1. Press the ‘Get Form’ button to access the Nursing Progress Note Template and open it in your browser.
2. Begin by entering the patient’s name and medical record number (MR#) at the top of the template. Make sure to double-check for accuracy.
3. Select the type of visit by checking the appropriate box: Initial Visit, Acute Care, Recertification, or Annual Exam.
4. Indicate whether the patient has Advance Directives by selecting ‘Yes’ or ‘No’.
5. Document the date of the visit correctly under the date section.
6. In the Review of Systems (ROS) section, mark 'neg' for any systems that are not affected, such as constitutional, eyes, ENT, respiratory, and so forth.
7. In the History section, indicate the source of history obtained by checking the relevant box: Patient, Family, Nursing Staff, Chart, or Therapy Staff.
8. For the Functional Status section, assess and mark the patient's ability in Activities of Daily Living (ADLs) such as transfers, feeding, bathing, dressing, and grooming.
9. In the Physical Exam/Clinical Data section, assess and document the clinical findings for the various body systems, ensuring all points are checked accurately.
10. For the Assessment & Plan section, summarize the patient's condition and note their need for ongoing nursing facility care.
11. Log the signatures of the Nurse Practitioner/Resident and the Attending physician along with the respective dates.
12. Once all sections are completed, save your changes, and choose to download, print, or share the completed Nursing Progress Note Template.

Start filling out your Nursing Progress Note Template online today to ensure accurate and efficient patient documentation.