The Purpose and Importance of Nurse Progress Notes

• The purpose of progress notes for nurses and what needs to be included
• Breakdown of the SOAPI (Subjective, Objective, Assessment, Plan, and Interventions) method for progress notes
• Example of nursing progress note as well as tips for making one’s notes clear and concise

Throughout nursing school and early in your nursing career, you may repeatedly hear that one of the most important responsibilities as a nurse is documentation.  A motto often used is that “if it isn’t documented then it never happened”. 

As a new nurse, learning how and what to document in a patient’s chart can be challenging.  It is important to understand the importance of a nursing progress note, why they are important, and to observe an example progress note.

Whether you are new to the nursing field or have been practicing for many years, it is always important to understand nursing progress notes and to have a refresher as needed. 

Purpose of Nurse Progress Notes

Nurse progress notes are pieces of documentation that are kept in the medical record during a patient’s care.  Nurses are often the medical professionals that spend the most time with patients, and they are able to add special details about the care the patient is receiving, their recovery, and their progress.

These notes help medical professionals to keep track of the medications and care a patient receives and allow the patient’s medical record to be current and up to date as much as possible.  Nurse progress notes can also aid physicians in creating updated care plans as the patient’s condition changes.

The rule of thumb when it comes to writing a great nursing progress note is to always include as much detail as possible.  It is better to have more information rather than not enough information.  The details in the nurse progress note will aid the patient’s physician in understanding how the patient is responding to their treatment regimen and if there needs to be any changes.

Here are some common elements to include in a nurse’s progress note:

• Date and time
• Patient’s name
• Physician and nurse name
• General description of the patient
• Reason for care
• Vital signs and initial health assessment
• Results of any tests or bloodwork
• Diagnosis and care plan
• Patient’s response to treatment including medication effectiveness
• Instructions for further care
• Any patient education given
• Additional observations

SOAPI Method for Nurse Progress Notes

Many nurses have utilized the SOAPI method when writing nursing progress notes.  SOAPI stands for Subjective, Objective, Assessment, Plan, and Interventions.  Although many facilities utilize the SOAPI method, each facility may want to utilize a different format or template so be certain to ask how they like their nurse progress notes to be completed.

Gather subjective information

After the nurse has gathered the date, time, and patient’s name, begin the nurse progress note by requesting information from the patient.  This information is likely subjective and limited to the patient’s knowledge and their personal experience.  Subjective information includes the patient’s pain level, the reason for treatment, and any concerns that they may have.

Record objective information

After speaking with the patient, gather objective information to include in the progress notes. This includes vital signs, observable symptoms, and the results of any tests and bloodwork. Objective information will often support the subjective information that the patient provided which then helps the diagnosis of the patient.

Record your assessment

Record notes about the patient’s condition based on the conclusions from the patient’s symptoms and objective data.  The assessment also includes any medications that the physician has prescribed and the patient’s response.  Note any changes in the patient’s appearance, attitude, and symptoms since their treatment began.

Care Plan

This will include any course of action that is planned for the patient’s future treatment. Another important piece of information to include is any alternative treatments offered or treatments refused by the patient.  Any patient refusals are important to document.

Interventions

This includes any additional facts about the care the patient received during your shift such as details about the medications administered, any patient requests, and any other observations that were made.

Nurse Progress Note Example

If one is new to nursing or needs a refresher, it can be helpful to have an example of what a nurse progress note should look like.  The notes will differ, depending on the specialty or type of nursing care being provided.  Here is an example of what a nurse progress note may look like in the long-term care specialty:

Date: 3/26/2023

Time: 2200

Patient Name: Jane Doe

Nurse on duty: Katy Luggar-Schmit, LPN

Jane Doe is an eighty-year-old female who was admitted to our memory care unit on 3/24/2023 at 1300.  During this shift, Jane has been smiling, socializing with fellow residents, and getting adjusted to her new home.  No concerns have been noted.  Patient states to this nurse, “I like it here.” Jane is on a puree diet and tonight she completed eighty percent of her supper.  B/P is 108/72, P 74, T 98.4, R 16, and O2 98% room air.  Jane took all evening medications as ordered and is currently resting in bed for the evening.  The oncoming nurse has received all updates on Jane and the nurse monitoring will continue throughout the night. Katy Luggar-Schmit, LPN———————————————————————————————–

As one can see, there is a line after the signature to cover any remaining space on that line.  The line ensures that the nurse’s progress note is more complete and prevents any information from being added to that line.  The next nurse progress note will be made a space after the last one.

Other Nurse Progress Note Tips

Be objective

Be as objective as possible when writing nurse progress notes and try to only include facts and observations.  This helps to keep the nurse’s progress notes accurate.

Be as Brief as Possible

While it is important to have details in the nurse progress note, it is equally important to make them as concise and simple as possible.  Nurse progress notes often need to be read quickly so the quicker another medical professional can read through the note while still receiving pertinent information the better.

The Bottom Line

Nurse progress notes are an essential piece of the patient’s medical record.  Nurse progress notes help summarize the patient’s care and treatment plan in one place that is easily accessible by all medical professionals involved in the patient’s plan of care.  

Nurse progress notes also help medical professionals achieve positive health outcomes for the patient.  When it comes to writing a great nurse progress note, practice makes perfect.  The more progress notes that a nurse writes, the more confident and efficient the nurse will become with progress notes.  

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