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hello everyone welcome back to nursing with the know me its nurse nate today were going to talk about progress notes im going to give you a bunch of examples of how to document certain situations so that you know what to do hopefully you can take some screenshots situation number one you gotta fall you can say patient had on witness fall with no injury on this date at 15 30 this nurse was alerted to the patients room by cna patient was noted to be on the floor parallel to bed with head towards the head of bed patient denies pain no injury noted patient was assisted back to bed neuro checks initiated vital signs were stable dr oliver was notified at 1600 daughter nancy was notified via phone at 16 15. well continue to monitor for change and condition you always have to have doctor notification you always have to have family notification and neurocheck started if applicable and also really what you could add in here is when asked patients stated he was trying to get to the bathroom
