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In this tutorial, the focus is on writing a progress note, which is essential in nursing to document a patient's medical status, assessments, treatments, and responses during a shift. The lesson outlines the types of progress notes, what information to include, and key considerations before writing. A progress note serves as a chronological narrative of the shift, capturing any issues encountered. For example, after conducting an initial assessment, a typical note might include the date and time, a statement of physical assessment completion, vital signs being normal, the patient's alertness, and any pain complaints, followed by the nurse's signature.
