How to write objective, concise and professional Progress Notes. 4 pages of sample progress notes included.

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Pat 15th Feb 2018
how to write a significant change progress note
Solange 15th Feb 2018
Hi Pat, I don’t know if I understood your question. Progress Notes are a succinct summary of relevant facts occurred to clients on your shift. For instance, if support for a client is increased, due to health deterioration, you should write what support was provided and how the client managed (mood). Stick to essential information you have observed and report what client says oo/and feels. Write events in an objective, respectful, and non-judgmental manner; refrain from using words like: uncooperative, abusive, hysterical, but if you need adverbs have them accompanied by an explanation/clarification of the circumstances. The significance of Progress Notes depends on following the guidelines and your choice of words.
Melissa 14th Feb 2018
Progress notes are an ongoing struggle for all, this is a great little refresher. Thanks!
Talita 17th Feb 2018
Thanks for your feedback Melissa!
Wendy 16th Aug 2017
Progress notes are challenging and I believe we all need education on that especially in care plans where they are Patient centred, and getting all staff involved.
Rhonda 13th Aug 2017
I would like to know how to write better progress notes as a registered nurse
judy 9th Sep 2009
fabulous,thanks so much...looking forward very much to the identifying needs, writing goals write up.