Charting a Nursing Progress Note (+Examples)

A nursing progress note is a documentation that records the ongoing care, observations, and interventions provided by a nurse during a patient’s hospitalization or healthcare visit. It is an essential part of the patient’s medical record and serves as a communication tool among healthcare professionals involved in the patient’s care.

Key Components of a Nursing Progress Note

The nursing progress note typically includes objective and subjective information about the patient’s condition, as well as any changes or improvements observed over time. It may contain the following components:

1. Patient information: Identifying details such as the patient’s name, age, medical record number, and date of admission.
2. Assessment: Objective data gathered by the nurse, including vital signs, physical examination findings, laboratory results, and any other relevant information related to the patient’s health status.
3. Nursing interventions: Actions taken by the nurse to address the patient’s needs. This may involve administering medications, providing treatments, assisting with activities of daily living, monitoring fluid intake and output, or implementing specific care plans.
4. Observations: Subjective information and observations made by the nurse, such as the patient’s complaints, pain level, mood, behavioral changes, or responses to treatment.
5. Evaluation: The nurse’s assessment of the effectiveness of the interventions and the patient’s progress or lack thereof. This may include changes in the patient’s condition, any complications, or improvements noted since the last note.
6. Care plan adjustments: Any modifications made to the patient’s care plan based on the observations and evaluation.

• Nursing progress notes are typically written in a concise and objective manner, using standardized terminology and language.
• They provide a chronological record of the patient’s care and serve as an essential reference for healthcare professionals involved in the patient’s treatment, ensuring continuity of care and facilitating communication between team members.

Common Formats Applied in Documenting Nursing Progress Notes

There are several formats used for documenting nursing progress notes. The specific format may vary depending on the healthcare facility, electronic health record (EHR) system, or individual preferences. Here are some commonly used formats for nursing progress notes:

1. Narrative Note Format: This format involves writing a detailed narrative description of the patient’s condition, assessments, interventions, and responses to treatment. It follows a chronological order and provides a comprehensive account of the nursing care provided.
2. SOAP Note Charting Format: SOAP stands for Subjective, Objective, Assessment, and Plan. This format separates different sections to organize the information effectively.
   • Subjective: Includes the patient’s complaints, symptoms, and any information provided by the patient or their family.
   • Objective: Contains the nurse’s objective observations, vital signs, physical assessments, and laboratory results.
   • Assessment: Summarizes the nurse’s analysis and interpretation of the patient’s condition based on the subjective and objective data.
   • Plan: Describes the nurse’s plan for ongoing care, including interventions, treatments, and any adjustments to the care plan.
3. PIE Note Charting Format: PIE stands for Problem, Intervention, and Evaluation. This format focuses on specific nursing problems or diagnoses.
   • Problem: Identifies the nursing problem or diagnosis based on the patient’s condition.
   • Intervention: Describes the nursing interventions or actions taken to address the problem.
   • Evaluation: Evaluates the effectiveness of the interventions and the patient’s response to treatment.
4. Focus Note Charting Format: This format emphasizes the patient’s current concerns or issues, called “focuses.” It includes the following components:
   • Data: Records subjective and objective data related to the focus.
   • Action: Describes the nursing interventions taken in response to the focus.
   • Response: Evaluates the patient’s response to the interventions.
5. DAR Note Charting Format: DAR stands for Data, Action, and Response. It is a concise format commonly used in some healthcare settings.
   • Data: Provides the relevant data or information regarding the patient’s condition.
   • Action: Describes the nursing actions taken based on the data.
   • Response: Evaluates the patient’s response to the actions or interventions.

• It’s important to note that the format used may depend on institutional guidelines and policies.
• Nurses should follow their facility’s specific documentation requirements to ensure consistency and accuracy in nursing progress notes.

Examples of Nursing Progress Notes

A. Narrative Format Nursing Progress Note Example

1. Patient Info:
   • Patient Name: John Doe
   • Age: 55
   • Medical Record Number: 123456
   • Date of Admission: July 8, 2023
   • Date: July 10, 2023
   • Time: 09:00 AM
2. Subjective: The patient reports feeling less pain in his abdomen today compared to yesterday. He states that the prescribed pain medication has been effective in managing his discomfort. The patient also mentions feeling slightly fatigued but denies any other new concerns or symptoms.
3. Objective:
   • Vital Signs: Blood pressure 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths per minute, temperature 37.2°C (oral).
   • Abdominal Assessment: The incision site from the appendectomy appears clean, dry, and intact. No signs of redness, swelling, or drainage observed. The patient reports minimal tenderness upon palpation.
   • Bowel Sounds: Normal bowel sounds auscultated in all quadrants.
   • Urinary Output: 250 mL clear yellow urine output since the last note.
   • Pain Assessment: The patient rates his pain as 2/10 on the numeric rating scale. Pain is localized to the lower right abdomen and is described as a dull ache.
4. Assessment: The patient demonstrates stable vital signs and improved pain control following the appendectomy. The incision site shows signs of healing without any signs of infection or complications. Normal bowel sounds indicate a return of bowel function. The patient reports mild fatigue, which could be expected postoperatively.
5. Plan:
   • Continue to monitor vital signs every 4 hours or as per nursing protocol.
   • Administer prescribed pain medication, as needed, to maintain pain control.
   • Encourage the patient to ambulate and perform deep breathing exercises to prevent complications and promote recovery.
   • Provide education to the patient regarding postoperative care, wound care, and signs of infection.
   • Collaborate with the healthcare team for timely removal of surgical staples or sutures.
   • Assess and address any concerns or questions raised by the patient and provide appropriate support.

• This progress note indicates that the patient, John Doe, is progressing well following the appendectomy.
• Vital signs are stable, pain is well-controlled, and the incision site is healing without complications.
• The nursing plan focuses on monitoring, pain management, patient education, and promoting recovery.
• The patient will continue to be closely monitored for any changes in condition or new developments.

B. SOAP Format Nursing Progress Note Example

1. Patient Info:
   • Patient Name: Emily Johnson
   • Age: 32
   • Medical Record Number: 789012
   • Date of Admission: July 5, 2023
   • Date: July 10, 2023
   • Time: 10:30 AM
2. Subjective: The patient reports feeling better and more energetic today. She states that her pain has significantly decreased since the last note. The patient mentions that she had a good night’s sleep and is able to move around with less discomfort. She expresses satisfaction with the care provided.
3. Objective:
   • Vital Signs: Blood pressure 120/70 mmHg, heart rate 82 bpm, respiratory rate 16 breaths per minute, temperature 36.8°C (oral).
   • Surgical Site: The abdominal incision from the cesarean section is clean, dry, and intact. No signs of redness, swelling, or drainage observed. The patient reports minimal tenderness upon palpation.
   • Lochia: Lochia is decreasing in amount and changing from bright red to pinkish-brown.
   • Breastfeeding: The patient successfully breastfed her newborn twice since the last note. Latching appears to be effective, and the patient reports minimal discomfort during feeding.
   • Urinary Output: 200 mL clear yellow urine output since the last note.
4. Assessment: The patient’s condition has improved since the cesarean section. Vital signs remain stable within normal limits, and the patient reports decreased pain and increased energy levels. The surgical site is clean and shows signs of healing without any signs of infection. Lochia is progressing as expected, indicating postpartum recovery. Breastfeeding is successful with minimal discomfort reported.
5. Plan:
   • Continue to monitor vital signs every 4 hours or as per nursing protocol.
   • Encourage the patient to ambulate, perform deep breathing exercises, and use pain management techniques to promote recovery.
   • Assess and provide support for breastfeeding, addressing any concerns or difficulties that may arise.
   • Educate the patient about postpartum care, including wound care, signs of infection, proper hygiene, and emotional well-being.
   • Collaborate with the healthcare team to initiate newborn care and discharge planning.
   • Evaluate the patient’s readiness for discharge and provide appropriate education and resources for home care.

• This SOAP progress note documents the positive progress of the patient, Emily Johnson, following a cesarean section.
• Vital signs are stable, pain is decreased, and the surgical site is healing well. Lochia is progressing as expected, and breastfeeding is successful.
• The nursing plan focuses on monitoring, promoting recovery, supporting breastfeeding, providing education, and facilitating discharge planning.
• The patient will continue to receive comprehensive care and support to ensure a smooth transition to postpartum recovery at home.

C. PIE Format Nursing Progress Note Example

• Patient Name: Sarah Thompson
• Age: 65
• Medical Record Number: 234567
• Date of Admission: July 8, 2023
• Date: July 10, 2023
• Time: 11:15 AM

1. Problem: Impaired Mobility related to recent hip fracture. Intervention: Assist patient with ambulation, provide pain management, encourage use of assistive devices. Evaluation: Patient demonstrates improved mobility and reports decreased pain.
2. Problem: Risk for Falls related to impaired mobility. Intervention: Implement fall prevention measures, keep pathways clear, provide assistance during transfers. Evaluation: No falls reported, patient remains safe and free from injury.
3. Problem: Acute Pain related to recent hip fracture. Intervention: Administer prescribed pain medication, assist with positioning, provide comfort measures. Evaluation: Patient reports pain level decreased from 8/10 to 3/10, pain is manageable.
4. Problem: Anxiety related to hospitalization and surgical procedure. Intervention: Provide emotional support, engage in therapeutic communication, offer relaxation techniques. Evaluation: Patient appears calmer, reports reduced anxiety levels.
5. Problem: Impaired Sleep Pattern related to pain and hospital environment. Intervention: Encourage relaxation techniques, provide a quiet and comfortable environment, administer sleep aids as prescribed. Evaluation: Patient reports improved sleep quality, stating feeling more rested upon waking.
6. Problem: Risk for Constipation related to decreased mobility and pain medication. Intervention: Encourage fluid intake, provide dietary fiber, administer prescribed stool softeners. Evaluation: Patient reports regular bowel movements, no signs of constipation observed.
7. Problem: Risk for Impaired Skin Integrity related to immobility and pressure points. Intervention: Reposition patient every 2 hours, provide skin care, use pressure-relieving devices. Evaluation: Skin remains intact, no signs of redness or breakdown.

• This progress note documents the nursing interventions and evaluations for various identified problems in the patient, Sarah Thompson, following a hip fracture.
• The interventions implemented are focused on promoting mobility, preventing falls, managing pain, addressing anxiety and sleep disturbances, preventing constipation, and maintaining skin integrity.
• The evaluations show positive outcomes, such as improved mobility, reduced pain, reduced anxiety, improved sleep pattern, regular bowel movements, and intact skin.
• The nursing care plan continues to address the patient’s needs and monitor progress to support recovery and well-being.

D. Focus Charting Format Nursing Progress Note Example

1. Patient Info:
   • Patient Name: Michael Anderson
   • Age: 45
   • Medical Record Number: 345678
   • Date of Admission: July 6, 2023
   • Date: July 10, 2023
   • Time: 12:45 PM
2. Focus: Pain management
   1. Data: The patient reports moderate pain in his lower back, rated as 6/10 on the pain scale. He describes the pain as a dull ache that worsens with movement. The pain interferes with his ability to perform daily activities and get restful sleep. The patient states that he has been taking the prescribed pain medication as directed but feels that it provides only partial relief.
   2. Action: Administered prescribed pain medication, provided backrest support, and assisted the patient with repositioning for comfort. Applied heat therapy to the affected area. Collaborated with the healthcare team to review the pain management plan and discuss alternative strategies.
   3. Response: The patient’s pain decreased to 4/10 within 30 minutes of medication administration. He reported feeling more comfortable and experienced improved mobility. The patient was able to engage in light activities without significant pain. He expressed gratitude for the nursing interventions and reported a better night’s sleep.
3. Focus: Respiratory status
   1. Data: The patient presents with a persistent cough, which is productive of thick, yellowish sputum. Lung auscultation reveals coarse crackles bilaterally in the lower lobes. Oxygen saturation levels range between 92-94% on room air. The patient denies chest pain or shortness of breath at rest but experiences mild dyspnea on exertion.
   2. Action: Assisted the patient with controlled coughing and deep breathing exercises. Administered prescribed nebulizer treatments as scheduled. Monitored oxygen saturation levels regularly. Encouraged fluid intake and provided education on airway clearance techniques.
   3. Response: The patient’s cough became less frequent and the sputum consistency improved after implementing the interventions. Lung auscultation revealed decreased crackles in the lower lobes. Oxygen saturation levels remained within the acceptable range, and the patient reported decreased dyspnea on exertion. The patient demonstrated understanding of airway clearance techniques and was actively engaged in self-management.
4. Focus: Nutritional intake
   1. Data: The patient’s appetite has been poor since admission. He reports feeling nauseous and has experienced a weight loss of 3 kg over the past week. The patient’s dietary intake consists mainly of small portions of bland food and fluids.
   2. Action: Provided frequent small meals and snacks to promote adequate calorie intake. Offered antiemetic medication as prescribed. Collaborated with the dietitian to modify the patient’s diet based on preferences and nutritional needs. Monitored weight regularly.
   3. Response: The patient’s nausea improved with the antiemetic medication, leading to increased tolerance of food and fluids. He demonstrated improved appetite and began consuming larger portions of balanced meals. The patient’s weight remained stable, and he expressed satisfaction with the modified diet plan.

• In this progress note, the nursing interventions and patient responses are documented using the focus charting format.
• The focus areas include pain management, respiratory status, and nutritional intake.
• The interventions implemented address the specific concerns identified, and the patient’s responses indicate positive outcomes and improvement in their condition.
• The nursing care plan continues to focus on these areas, aiming to provide holistic care and support the patient’s recovery and well-being.

E. DAR Format Nursing Progress Note Example

1. Patient Info:
   • Patient Name: Emma Carter
   • Age: 28
   • Medical Record Number: 456789
   • Date of Admission: July 8, 2023
   • Date: July 10, 2023 Time: 02:30 PM
2. DAR #1:
   1. Data:
      • Patient experiencing increased shortness of breath at rest, respiratory rate 24 breaths per minute, oxygen saturation 88% on room air.
      • Lung auscultation reveals bilateral wheezing and decreased breath sounds.
      • Cough productive of thick, greenish sputum.
      • Elevated temperature of 38.5°C (oral).
   2. Action:
      • Administered prescribed bronchodilator medication.
      • Assisted patient with controlled coughing and deep breathing exercises.
      • Provided supplemental oxygen at 2 liters per minute via nasal cannula.
      • Monitored vital signs and oxygen saturation levels every 2 hours.
      • Initiated prescribed antibiotics for suspected respiratory infection.
      • Encouraged increased fluid intake and provided education on the importance of hydration.
      • Collaborated with the healthcare team to review and adjust the respiratory care plan.
   3. Response:
      • Following bronchodilator administration, patient’s respiratory rate decreased to 20 breaths per minute, and wheezing improved.
      • Patient demonstrated effective coughing and reported expectorating thinner sputum.
      • Oxygen saturation levels improved to 92% on supplemental oxygen.
      • Patient’s temperature reduced to 37.8°C after receiving antipyretic medication.
      • Patient verbalized understanding of the importance of fluid intake and increased consumption of fluids.
3. DAR #2:
   1. Data:
      • Patient complaining of generalized abdominal pain, rated as 7/10 on the pain scale.
      • Abdomen is tender to palpation in the lower right quadrant.
      • Reports decreased appetite and absence of bowel movements for the past two days.
   2. Action:
      • Administered prescribed pain medication and anti-inflammatory medication.
      • Applied a heating pad to the abdomen for pain relief.
      • Assisted patient with ambulation to promote bowel motility.
      • Provided education on the importance of fiber-rich diet and encouraged increased fluid intake.
      • Collaborated with the healthcare team to review and adjust the gastrointestinal care plan.
   3. Response:
      • Patient’s pain decreased to 4/10 following pain medication administration.
      • Abdominal tenderness in the lower right quadrant reduced slightly.
      • Patient reported passing gas and experienced mild relief in abdominal discomfort.
      • Patient expressed willingness to try dietary modifications and increased fluid intake.

• In this progress note, the nursing interventions and patient responses are documented using the DAR format.
• The two identified focuses include respiratory status and gastrointestinal discomfort.
• The interventions implemented address the specific concerns identified in each area, and the patient’s responses indicate positive outcomes and improvement in their condition.
• The nursing care plan continues to focus on these areas, aiming to provide effective symptom management and support the patient’s recovery.