Change in Condition Nursing Note Example
A change-in-condition note documents a significant change in a patient's status and the nursing actions and communication that followed.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
When a patient's condition changes, the record should let a reader reconstruct the sequence: what changed, when, what was found, who was told, and what happened next. Clear time stamps and closed loops are the point.
When this may be used
- After a change in status that required action or communication.
- In the fictional examples on this page, the actions are supplied by the scenario. This page teaches documentation; it does not decide what to do for a real patient.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Documentation, not clinical direction
The examples show how to document actions that the fictional scenario says occurred. They are not guidance about which interventions are needed for any real patient.
Components
What changed and when
The trigger.
What belongs here
- The change observed or reported, with time
What does not belong
- Vague "patient worse"
Assessment findings
Evidence.
What belongs here
- Findings actually obtained
What does not belong
- Assumptions
Actions taken
Care provided.
What belongs here
- Interventions performed
What does not belong
- Planned care written as done
Notification
Communication.
What belongs here
- Who, when, what was communicated
What does not belong
- Notifications that did not happen
Orders / communication
Result of notification.
What belongs here
- Orders received, read back
What does not belong
- Invented orders
Response and follow-up
Outcome.
What belongs here
- Reassessment, plan to monitor
What does not belong
- Assumed improvement
Short fictional example
- Narrative
- 1530: Patient oriented to person only; at 1200 was oriented ×4. Blood glucose 58 mg/dL by fingerstick. Hypoglycemia protocol initiated per standing order. Charge nurse informed at 1535.
More detailed fictional example
- Focus
- Change in respiratory status
- Data
- 1015: Patient states "I can't catch my breath." SpO2 88% on room air (95% at 0800). Respiratory rate 26. Using accessory muscles.
- Action
- Head of bed raised to 45 degrees. Oxygen applied at 2 L/min by nasal cannula per standing order. 1020: Provider notified by phone of SpO2, respiratory rate and patient statement. New order received for chest X-ray; order read back and confirmed.
- Response
- 1035: SpO2 93% on 2 L/min. Respiratory rate 22. Patient states "a little easier." Will continue to monitor SpO2 per order.
Annotated example
Notes on the detailed example above:
SpO2 88% on room air (95% at 0800)
— The change is shown by comparing with an earlier value.per standing order
— The action is tied to an existing order in the scenario.order read back and confirmed
— Communication and read-back are documented.1035: SpO2 93% on 2 L/min.
— Reassessment closes the loop.
Common mistakes
- No baseline for comparison.
- Leaving out who was notified and when.
- Documenting the notification without the response.
- Charting actions that happened later as if they happened first.
Good vs poor documentation
Weaker (fictional)
Pt SOB, O2 on, MD aware.
Stronger (fictional)
1015: SpO2 88% on room air. O2 at 2 L/min per standing order. 1020: provider notified by phone; chest X-ray ordered, read back.
Why: Specific findings, times and communication.
Blank educational template
Change in condition: Capture what changed and what happened next. Prompts only; nothing is prefilled.
- What changed and when
- [Change observed or reported, with time]
- Assessment findings
- [Findings actually obtained]
- Actions taken
- [Nursing actions actually performed]
- Notification
- [Who was notified, when, and what was communicated]
- Orders / communication received
- [Orders received and read back, if any]
- Response and follow-up
- [Reassessment findings and plan for follow-up]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
- Provider notification
- SBAR
- DAR notes
- NCLEX Physiological Adaptation review — Recognizing changes in condition.
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
- TeamSTEPPS — SBAR (Situation-Background-Assessment-Recommendation) — Agency for Healthcare Research and Quality (AHRQ).
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.