How to Create a Nursing Progress Note
1- To start a Nursing Note you have to access the Patient's Chart Face from the Chartroom after searching the patient and selecting the name.
As you access the Chart Face, go to the notes options and select the Nursing option marked in red.
You are now in the "NURSING PROGRESS NOTE":
2- Breakdown of the Sections in a Nursing Note:
A- Just a Brief Clinical Note
Clicking the Just a Brief Clinical Note button will add a subtitle to the yellow field. You are able to add a brief note for the patient.
B- Symptoms/Behavior
Next, let’s move on to Symptoms/Behavior. Simply click "Denies Symptom" If the patient doesn't have a specific symptom, otherwise select the associated "See list" button to input symptom-specific sentences into the body of your record. Remember to work from top to bottom of each list’s shrub to capture data in the most logical fashion.
In the example below:
Our patient doesn’t Deny Depression, so we click See list to the right of Denies Depression in the Symptoms list. The screen that appears next is called a “shrub.”
We click Depression still reported from the first column of the shrub. Next, we click Frequency and Duration from the first column and our shrub branches to display a second column. We choose Episodic and then the frequency as Daily and that the Mood lasts for hours. Each time you click an option on the shrub, the program inserts a corresponding sentence into your narrative (see screenshot below).
C- Behavior
The Behavior button can be used to document a wide variety of divergent behaviors. We have clicked the Behavior See list button and, from the buttons in the left column, chosen to record that our patient has Regular Medication Compliance and that she is Irregular in Participation in Activities. Click the Back button to return to the NURSING PROGRESS NOTE.
D- Somatic Symptoms
<p style="font-size:Common Questions
Problem: How to Create a Nursing Progress Note.
Solution: Follow the steps below to resolve quickly.
- Check prerequisites and permissions.
- Follow the configuration steps.
- Verify the result and retry if needed.
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