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In this tutorial, Nurse Nate discusses how to document progress notes effectively in nursing. He provides an example of documenting a patient fall, stating: the patient had an unwitnessed fall with no injuries on a specific date and time. Upon being alerted by a CNA, the patient was found on the floor, parallel to the bed, and denied pain, with no injuries noted. The nurse assisted the patient back to bed, initiated neuro checks, and monitored vital signs, which remained stable. Doctor notification was made, and family was informed afterward. Monitoring for any change in condition is essential, and documentation should include patient statements, such as the patient attempting to reach the bathroom.
