What is a skilled nursing progress note?
A skilled nursing progress note is a written record that documents the observations, assessments, and care provided by skilled nursing staff to patients. It serves as a communication tool among healthcare professionals and helps track the patient's progress and response to treatment.
What are the types of skilled nursing progress note?
There are several types of skilled nursing progress notes that are commonly used in healthcare settings. These include:
SOAP (Subjective, Objective, Assessment, Plan) Note: This type of progress note follows a structured format and includes subjective information provided by the patient, objective observations made by the healthcare provider, assessments of the patient's condition, and the plan for further care and treatment.
Narrative Note: This type of progress note is a more detailed narrative description of the patient's condition, progress, and response to treatment. It provides a comprehensive view of the patient's healthcare journey.
Flow Sheet Note: This type of progress note uses a flow sheet format to track specific patient parameters over time, such as vital signs, medications administered, and treatments provided.
Focus Note: This type of progress note focuses on a specific issue or problem related to the patient's healthcare, such as wound care or pain management. It provides detailed information and interventions regarding the specific issue.
Behavioral Note: This type of progress note focuses on the patient's behavior and mental health status, documenting any changes or concerns observed by the healthcare provider.
How to complete a skilled nursing progress note?
Completing a skilled nursing progress note requires attention to detail and accurate documentation. Here is a step-by-step guide on how to complete a thorough and informative progress note:
01
Begin by documenting the date and time of the progress note.
02
Include the patient's name and identification number for proper identification.
03
Start with the subjective information provided by the patient, including any symptoms, concerns, or changes in condition they have reported.
04
Document the objective observations made by the healthcare provider, such as vital signs, physical examination findings, or any tests performed.
05
Assess the patient's condition based on the subjective and objective information, and include any relevant diagnoses or changes in the patient's health status.
06
Develop a plan for further care and treatment, including any medications prescribed, therapies recommended, or follow-up appointments.
07
Ensure that the progress note is clear, concise, and includes all necessary information for proper communication and continuity of care.
08
Review and revise the progress note as needed, ensuring accuracy and completeness.
09
End the progress note with your name, designation, and contact information for reference.
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