Progress Notes For Nursing Template

When using a physical piece of paper, it's clear that you don't need to worry about accidentally erasing someone else's progress note. However, if multiple people have access to the same PDF, it's possible they could be editing it simultaneously from different computers- and accidentally delete the other person's notes! As such, we recommend setting out a clear policy or implementing digital safeguards on where and when to save changes to a patient's progress notes if you use this PDF digitally.

A patient identifier is an optional additional identifier for your patient in addition to their name and birth date—these are very important details. This could be a national or state-level identification number or an ID number assigned by your hospital to their patients.

There are many resources on writing good progress notes, but a few things always come up as examples of best practices. If you are writing notes by hand, ensure you write legibly to keep it easy for others to read. Keep your progress notes concise, including only the necessary information. Limit jargon and acronyms to a level that others in your team will understand. Finally, don't forget to add the date and time—our nursing process notes template can help you with this last one!