Nursing Progress Notes
A progress note is an entry that records the patient's status, care and response over a period of time. "Progress note" describes the purpose of the note; it can be written in several formats.
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
Progress notes connect separate assessments into a picture of change over time. A useful progress note compares with earlier findings (better, worse, unchanged) and states what happened in between, rather than repeating a checklist.
When this may be used
- Periodic updates required by the organization's policy (frequency varies).
- After a significant event or change.
- The format (narrative, DAR, SOAP, SOAPIE) depends on the organization.
Components
Current status
Where the patient is now.
What belongs here
- Assessment findings obtained
What does not belong
- Copied findings from an earlier shift
Change over time
Compare with baseline.
What belongs here
- Better, worse or unchanged, with evidence
What does not belong
- Unsupported conclusions
Care provided
What was done.
What belongs here
- Interventions performed
What does not belong
- Planned care as completed
Response and plan
Outcome and next steps.
What belongs here
- Response, follow-up items
What does not belong
- Invented orders
Short fictional example
- Progress note
- Pain rated 3/10 at 1500, compared with 6/10 at 0800. Walked in hallway three times today with walker and standby assistance, up from once yesterday.
More detailed fictional example
- Subjective
- Patient states "My knee is stiff but the pain is better than yesterday." Rates pain 3/10 at rest.
- Objective
- Right knee dressing clean, dry and intact. Walked 50 feet with walker and standby assistance at 1100 and 1400. Right foot warm with capillary refill less than 3 seconds.
- Assessment
- Pain lower than yesterday's reported 6/10; walking distance increased.
- Plan
- Continue scheduled walking per care plan. Reassess pain after physical therapy session at 1600.
Annotated example
Notes on the detailed example above:
better than yesterday
— Progress notes compare with an earlier baseline.Walked 50 feet… at 1100 and 1400
— Specific measures show progress.
Common mistakes
- Copying the previous note forward without reassessing.
- Listing findings without saying whether they changed.
- Using "no change" without stating what was assessed.
Good vs poor documentation
Weaker (fictional)
No change.
Stronger (fictional)
Pain 3/10 at rest, same as at 0800. Walked 50 feet with walker, unchanged from this morning.
Why: "Unchanged" should still show what was assessed.
Blank educational template
Shift summary: A concise summary of the shift. Prompts only; nothing is prefilled.
- Overall status
- [Summary of findings across the shift]
- Key events
- [Significant events with times]
- Care provided
- [Main interventions performed]
- Responses
- [Responses and reassessments]
- Pending items
- [Follow-up items for the next nurse]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
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.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.