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In this tutorial, the focus is on how to write a progress note in nursing. It covers the types of progress notes, essential information to include, and key considerations before writing one. A progress note documents a patient’s medical status, including assessments, care treatments, and the patient's progress and response during a shift. The purpose is to create a chronological narrative of the shift, noting any issues encountered. An example of a progress note includes the date and time, stating the completion of a physical assessment, normal vital signs, the patient's alertness, and the absence of pain. Proper documentation is essential for clarity and continuity of care.
