The nursing progress notes help medical students to keep their patient’s recovery and care record. This way the information about the patient is availed by the time the patient visits the clinic to avail medical services or treatment. It is also useful for doctors and nurses reference and then they update these progress reports as per patient’s condition. Writing these progress notes for nursing students can be bit challenging. Therefore, here we discuss few tops that can be used by nursing students to prepare progress notes effectively.
Types of nursing progress notes-
The nursing progress notes help in keeping the record of patient’s information including treatment, therapies, physical or psychological condition, etc. The doctors use these progress notes for reference so that the care and medicine given to the patient can be remembered. Here are two types of nursing progress notes that the nursing students may have to prepare such as: 1) Admission nursing progress notes, 2) Update care nursing progress notes.
Factors to include while writing nursing progress notes-
The nursing progress notes is required to be written in simple language along with known terminology, so that understanding the report will not be a difficult task. A few factors are discussed here that must be included while preparing nursing progress notes-
· Name, age, medical and record number of patient- This element helps in ensuring that patient is provided treatment for as per their need and their medicine or treatment is not mixed with other patients.
· Visiting time and date- It helps in tracking down the stages of patient’s treatment.
· Name of doctor and nurse- This way it will be easier to know which doctor or nurse is providing treatment to the patient.
· Medical issue- This helps in knowing that why the patient is seeking for medical treatment.
· Treatment details- With the help of this element it is easy to understand the sort of cure and treatment have been provided to the patient.
· Signs and assessments- The progress notes include signs like heart rate, blood pressure, etc. along with a description of patient’s condition observed during check-up.
· Risk or change in patient’s condition- The notes contain complications or changes that the patient experienced and requires doctor to be more careful during treatment.
While writing the nursing progress notes it is important that the student to follow SOAPI format. The SOAPI stands for subjective, objective assessment, plan and interventions.
i. Subjective contains the symptoms that patients have.
ii. Objective is based on the changes occurred in patient during treatment.
iii. Assessment is an evaluation process to understand the recovery level of patient.
iv. Plan helps in demonstrating the changes that patient needs by observing their symptoms.
v. Intervention is considered as the summary of all activities that the patient has gone through for treatment.
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