What is a Nursing Progress Notes Template?
Progress notes take up a large chunk of a nurse’s day, regardless of their specialty or workplace. As such, progress note-taking is a great skill to develop that is guaranteed to benefit your nursing career regardless of your future direction.
are a hugely important resource for informing clinical decision-making and medical record-keeping, and every nurse will have a different style of note-taking that works best for them. When it came to designing a template for nurses to take progress notes we knew we had to keep it simple but add in a few useful features to save time.
This nursing progress notes template is a free PDF resource for you to keep track of your patients’ progress notes in a pre-formatted structure with handy columns for the date, time, and nurse’s signature or initials.
How to Use This Progress Note Template for Nursing
It’s simple to get started using this PDF progress note template in your nursing practice, but to ensure you’re getting the most out of your template- follow the steps below.
Step 1. Download the PDF
The first step to start using this nursing progress note template in your practice is to download the PDF using the link on this page. Once you have downloaded the free PDF, just click within the interactive text boxes to start typing. Alternatively, you can print this PDF out and fill it in by hand if that’s more your thing.
Step 2. Add the date and time of your note
Every nursing progress note needs to include the date and time of your interaction to build a solid timeline for your patient and for medical record-keeping purposes. Add the date and time in the Date/Time column before you start writing the note so you don’t forget it.
Step 3. Add your progress note
We have left the progress note section blank for you to use your preferred method of note-taking. Many nurses use the SOAP, F-DAR, or PIE acronyms, and with our template, you can use whichever method you prefer for taking your progress notes.
Step 4. Add your signature or initials
Once you have written your progress note, add your signature or initials in the initials column. This is an important step for accountability, and for meeting the legal obligations for medical record keeping.
Step 5. Save your changes securely
The last step is to save your progress note securely. If you are using this template digitally, ensure everyone accessing the template understands how to use it without overwriting each other’s hard work.
Nursing Progress Notes Example (Sample)
Can’t wait to see what this template looks like when it’s completed? We have created example nursing progress notes using this template to illustrate what this template can look like when it’s all filled in.
Who Can Use this Nursing Template?
This template is designed for use by registered nurses (RN’s) who routinely take periodic progress notes on their patients. The structure of this template is designed for concise progress notes (not a whole medical history!) set out in chronological order. The concise nature of these progress notes makes it best for using on patients in an in-patient setting, where you may be looking after several patients on the ward at one time. As such, this template can be a great organizational tool.
This template can aid the progress note-taking process for nurses working in:
- Perioperative nursing
- Critical care
- Occupational health
- Hospice care
- Cardiac care
And many more! Additionally, this template may be used by nursing students or trainees who are still developing their progress note-taking skills.
Why is This Template Useful for Nurses?
This template was designed with nurses in mind, with the goal of saving them time and making their busy lives a little bit easier. Some of the useful points about using this template in your nursing practice are included below:
Use your preferred style
We have kept this template simple enough for you to use whichever note-taking style you prefer. Lots of templates add in extra headings you will never use, or sections that don’t apply to your patient. No such redundancies here!
Keep your notes organized
Our table format keeps your progress notes in a readable, chronological order. Just print out multiple copies to keep the progress notes going beyond the first page.
Provide evidence of your decision-making process
Our progress notes template puts your entry in the context of your patient’s full set of progress notes from all other nurses in their care team. As such, our completed progress notes template provides great evidence of your decision-making skills and teamwork for any continuing professional development (CPD) you are required to undertake.
Benefits of Using a Free Progress Note Template for Nursing
Having a note-taking structure where anyone on your patient’s care team can contribute, read previous progress notes, and quickly pick up where others have left off is a huge time-saver in nursing and becomes particularly important during handovers between shifts.
With the initials column in our template, you won’t need to be chasing up the anonymous author of a progress note again. Additionally, you will ensure each progress note entry is traceable and complete as a legal medical record for your patient.
Reduce administrative errors
Using a template serves as a helpful reminder for commonly forgotten details such as the date, time, or signature of the nurse completing the progress note. Don’t rely on your memory, and leave the reminders to us.
This template is designed to be used digitally or as a print-out, which can be super useful to make a smooth transition for practices crossing over into digital-only note-taking. We recommend taking notes digitally for security purposes and time-saving, not to mention it’s better for the environment.
Keep notes well formatted
Notes with multiple authors can quickly become chaotically formatted! Using our progress notes template with pre-made formatting saves you time formatting your own notes. It is also necessary that progress notes can be easily shared with third parties such as insurance companies, and using a well-formatted template will help ensure others can easily read and understand these progress notes.
Why Use Carepatron For Nursing Notes?
Your progress notes are important medical records that will include sensitive patient information with a legal requirement to be stored securely. As such, having one reliable, secure place to store your notes is a big help in meeting your legal obligations.
Carepatron offers a digitally encrypted, HIPAA-compliant method to store your progress notes, along with all the other documents making up your patient’s medical record. As well as being secure, Carepatron is easily accessible on mobile or desktop for all members of your patient’s care team.
Beyond storing your progress notes, you can also create, access, edit and share your notes through Carepatron with others in your team, or with your patients through Carepatron’s client portal.
Carepatron also offers AI-powered speech-to-text dictation software, compatible with all our clinical templates, as well as a whole suite of useful practice management features such as appointment scheduling, coding, billing management, and video call functionality.