A nursing home progress note is the physician’s or nurse practitioner’s note of a visit to a resident in a nursing home or long-term care home: why you came, what nursing reports and the trends show, the exam, the medicine review, goals of care, and the orders. Copy the free template, see a nurse-requested visit for new confusion and a review after a hospital stay for pneumonia, and check what each part of a long-term care visit note needs.
Blank nursing home progress note template
FreeNURSING HOME PROGRESS NOTE Resident: [Name, date of birth] Home, unit, and room: [Nursing home or long-term care home, unit, room] Date and time: [Date and time of visit] Visit type: [Routine review, visit requested by nursing, after a fall, after a hospital return, or follow-up of a change] Clinician: [Name, credentials, attending physician or nurse practitioner] Others present: [Charge nurse, care aide, family, decision-maker, interpreter, or none] Code status on file: [Resuscitation and hospital transfer wishes, and the date last confirmed] REASON FOR VISIT Concern: [What nursing, the resident, or family raised, in their words, and when it began] Baseline: [Usual cognition, communication, mobility, eating, and continence, from the care plan or staff who know the resident] Main conditions: [Active diagnoses that bear on today's visit] Since the last visit: [Hospital stays, emergency visits, specialist visits, and orders from the on-call clinician] REPORTS AND TRENDS Nursing report: [Charge nurse's account and recent nursing notes] Care aide report: [Eating, drinking, toileting, transfers, sleep, and behavior seen on each shift] Resident's account: [Symptoms in their words, or why they can't report them] Family concerns: [What family or the decision-maker have raised] Vital signs: [Temperature beside the resident's baseline, pulse, BP sitting and standing if able, RR, SpO2 on room air or oxygen] Weight: [Today's weight, the last monthly weights, and the change in kg and percent] Intake: [Share of meals eaten, fluids in mL a day, supplements, coughing or choking with meals] Bowel and bladder: [Last bowel movement and usual pattern, continence, urine output and color, catheter] Sleep and behavior: [Sleep pattern, agitation, responsive behaviors, and the behavior tracking record] Pain: [Score and scale, with a nonverbal scale for residents who can't rate it] EXAMINATION General and cognition: [Alertness, attention, orientation, and a delirium screen, compared with baseline] Focused findings: [The systems tied to the concern, compared with the last exam] Skin: [Pressure injuries by site, size, and stage; wounds; bruises] Mobility: [Transfers, gait, aids, and change from baseline] MEDICATION REVIEW Medication administration record: [Scheduled doses given, held, or refused, and PRN use over the past 2 to 4 weeks] Recent changes: [Medicines added or changed by on-call, a specialist, or a hospital, with dates] Higher-risk medicines: [Anticholinergics, sedatives, antipsychotics, opioids, anticoagulants, insulin, or diabetes medicines that cause lows: indication and dose checked] Deprescribing: [Medicines stopped, tapered, or kept, and the reason for each] RESULTS AND SAFETY EVENTS Labs: [Results since the last visit, beside earlier values] Other tests: [Imaging, cultures, ECG, or none] Falls: [Date, what happened, injury, post-fall checks, and changes made] Pressure injuries: [New or healing, stage, and the turning, surface, and dressing plan] Infection: [Symptoms and signs present or absent, whether the criteria for antibiotics are met, cultures, and the decision] Restraints and alarms: [Any in use and the reason, or none] ASSESSMENT AND PLAN Summary: [Age, main conditions, reason for visit, and whether the resident is better, the same, or worse than baseline] Problem 1: [Problem, likely cause, and plan] Problem 2: [Problem, likely cause, and plan] Chronic conditions: [Status, and whether targets and routine checks still fit the resident's goals] GOALS OF CARE AND COMMUNICATION Capacity: [Whether the resident can make today's decisions, and how you judged it] Goals: [What matters most to the resident now, in their words] Code status and transfer: [Resuscitation, hospital transfer, and treatment limits; confirmed or changed today, and with whom] Decision-maker: [Name and relationship] Family update: [Who you spoke with, how, what was discussed, and their questions] Care team: [Nursing, pharmacist, dietitian, therapists, or speech-language pathologist updated] ORDERS AND FOLLOW-UP Orders: [Each new, changed, or stopped order, with dose and route] Monitoring: [What nursing should check, how often, and for how long] Call the clinician if: [Specific thresholds and signs] Next review: [Date, or the routine schedule] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Long-term care home, visit requested by nursing, nurse practitioner with the charge nurse
Visit requested by the evening charge nurse. 89-year-old woman, 3 years in the home. Alzheimer’s dementia, moderate; hypertension; osteoarthritis of both knees. Concern: “She’s much more muddled for 2 days, and her urine is dark and smells strong.” Baseline, from the care plan and the staff who know her: oriented to person, knows staff by face, chats in short sentences, walks to the dining room with her walker and a staff member nearby, wears a brief at night, and eats most of each meal. No hospital or emergency visits since my last review. Code status on file: do not resuscitate; care in the home, with transfer only if comfort can’t be kept here; confirmed with her son in June.
Nursing: confusion began 2 days ago and is worse in the evenings. Called out for her mother overnight and slept about 4 hours. Picking at her clothes; no hitting or wandering. Care aides: eating about half of each meal, down from most; refused the juice cart twice. The night nurse dipped a urine sample yesterday: positive for leukocytes and nitrites. No new daytime wetting, straining, crying out, or holding her lower belly when passing urine. Bowel record: last bowel movement 4 days ago; usual every 1 to 2 days. Fluid record: 850, 900, and 780 mL over the past 3 days, against her usual 1,400 mL. Vital signs: temperature 37.1 °C (98.8 °F), her baseline 36.8 °C; pulse 88; BP 112/64 sitting, usually in the 130s systolic; RR 16; SpO2 95% on room air. Weight 58.1 kg, against 58.6 and 58.4 kg the 2 months before. PAINAD 1 at rest and 2 on standing, unchanged.
In the lounge, drowsy but rousable to voice, picking at her cardigan. Could not keep attention on a short question or say the days of the week backward. CAM positive: an acute change that fluctuates, inattention, rambling speech, and drowsiness. Not oriented to place, which is new for her. Mouth dry. Chest clear. Heart regular, no murmur. Abdomen mildly distended, soft, not tender; no suprapubic tenderness; bladder scan after voiding 110 mL. No tenderness at the costovertebral angles. Skin intact over the sacrum and heels. Moves all limbs; no new focal weakness. Gait not tested today.
MAR reviewed for the past 4 weeks. Scheduled: donepezil 10 mg at bedtime, raised from 5 mg 7 weeks ago; amlodipine 5 mg daily; acetaminophen 650 mg three times daily; vitamin D3 1,000 units daily. New: oxybutynin 5 mg twice daily, started 12 days ago by the on-call physician for daytime urge incontinence, which began after the donepezil increase. All doses given; no PRN sedatives used. Oxybutynin is strongly anticholinergic: it can cause confusion, constipation, and a dry mouth in older adults with dementia, and it works against donepezil. Adding it to treat incontinence that followed the donepezil increase is a prescribing cascade. Decisions: stop oxybutynin today. Hold amlodipine while her intake is low. Keep donepezil at 10 mg for now; if the daytime incontinence returns once the delirium clears, lower donepezil to 5 mg rather than add another bladder medicine.
Bloodwork drawn this morning, ordered by phone yesterday: sodium 147 mmol/L, 141 in July; creatinine 1.3 mg/dL (112 µmol/L), her baseline 1.0 mg/dL (88 µmol/L); glucose 115 mg/dL (6.4 mmol/L); white count 7.4, normal. Urine dipstick positive for leukocytes and nitrites; no culture sent. Infection review: no fever by the home’s definition, no burning or pain on passing urine, no new frequency or urgency, no suprapubic or flank pain, no visible blood, no rigors, chest clear. A positive dipstick with confusion alone does not meet the criteria for starting antibiotics in a resident without a catheter: this is bacteriuria without symptoms, and an antibiotic would bring side effects and resistance without benefit. No falls in the past month. No pressure injuries. No restraints.
89-year-old woman with moderate Alzheimer’s dementia and delirium for 2 days, worse than her baseline. Likely causes, together: a new anticholinergic, dehydration with a rise in creatinine and sodium, and constipation. No sign of urinary infection or pneumonia. Delirium: oxybutynin stopped; keep her routine, glasses, and hearing aid; lights up by day and low at night; her son to visit; no antipsychotic or sedative. Dehydration: fluids offered every hour while awake, aiming for 1,500 mL a day; amlodipine held; recheck sodium and creatinine in 3 days. Constipation: daily osmotic laxative, with a suppository tonight if needed. Urge incontinence: prompted toileting every 2 hours by day; donepezil plan as above.
Not capable of today’s treatment decisions: she could not take in or weigh the choices. Code status unchanged. Phoned her son, her decision-maker, at 4:15 p.m. Explained the delirium, the medicine most likely behind it, and why an antibiotic for the urine test would do more harm than good. He asked whether we might be missing an infection; went through the signs the nurses will watch for, and that we will treat if they appear. He agreed with the plan and will visit tomorrow afternoon. Charge nurse and the home’s pharmacist updated.
Discontinue oxybutynin. Hold amlodipine; restart if systolic BP is 150 or higher on 2 days in a row, and tell me. Polyethylene glycol 3350, 17 g in 250 mL of fluid daily. Bisacodyl 10 mg suppository once tonight if no bowel movement by 6 p.m. Fluids offered every hour while awake; intake and output record and bowel record for 72 hours. Vital signs and CAM each shift for 72 hours. Sodium and creatinine in 3 days. No further urine tests unless urinary symptoms or fever appear. Call me or the on-call clinician for a temperature above 37.8 °C (100 °F), or more than 1.1 °C above her baseline; pain or burning on passing urine, new frequency, visible blood, or flank pain; drowsiness that makes drinking unsafe; systolic BP below 90; or SpO2 below 92%. Review in 3 days, sooner if called.
Nursing home, routine review 5 days after return, attending physician with the resident and his daughter
Routine review 5 days after return from hospital. 84-year-old man, in the home 18 months since a right-sided stroke left him with left-sided weakness and mild dysphagia. Also atrial fibrillation, type 2 diabetes, and benign prostatic hyperplasia. Admitted for 6 days with right lower lobe pneumonia, likely from aspiration; treated with IV ceftriaxone, then amoxicillin-clavulanate by mouth, finishing 7 days in total the day after he came back. Discharge summary and medicine list reviewed. Baseline before admission: walked 15 m with a walker and one staff member, fed himself after set-up, ate minced and moist food with thin fluids, and read the paper daily. Code status on file: full resuscitation, with hospital transfer for any serious illness.
Nursing: no fever since return; cough less often, now mostly after drinking. Needed two staff for transfers for 3 days, now one. Care aides: eats about half of each meal and tires halfway through; coughs with some sips at breakfast. The home’s speech-language pathologist assessed him on day 2: minced and moist food, mildly thick fluids, sitting upright for meals and 30 minutes after, supervised small sips. Fluids 1,200 to 1,400 mL a day. Bowels every 2 days; voiding well. Vital signs: temperature 36.7 °C (98.1 °F); pulse 76, irregular; BP 124/70; RR 18; SpO2 94% on room air, 95% before admission. Weight 67.4 kg (148.6 lb), against 71.2 kg (157.0 lb) at the monthly weight 4 weeks ago: a loss of 3.8 kg, or 5.3%. Capillary glucose 88 to 140 mg/dL (4.9 to 7.8 mmol/L) over 5 days. No pain at rest; his tailbone is sore when he lies on his back.
Sitting up in a wheelchair, alert, oriented, and talking in full sentences. Breathing comfortably. Crackles at the right base, fewer than described at discharge; no wheeze. Heart irregularly irregular, no murmur. No leg swelling. Tongue coated; upper denture loose. Stage 2 pressure injury on the sacrum, 1.5 by 1 cm, pink base, no slough, first noted on his return; heels intact. Left arm and leg weakness unchanged from the stroke. Stood with one staff member and his walker and walked 6 m, slower than his baseline. BP 126/72 lying and 118/68 standing, with no dizziness.
Hospital list checked against the MAR and his list from before admission. Apixaban 5 mg twice daily: the right dose; he meets 1 of the 3 criteria for the lower dose, age 80 or over, but weighs more than 60 kg and his creatinine is below 1.5 mg/dL. Metformin 1,000 mg twice daily before admission; A1C 6.4% in September, and he now eats half his meals and is losing weight: reduced to 500 mg twice daily, with a target A1C below 8.0% given his frailty. Pantoprazole 40 mg daily, started in hospital to prevent stress ulcers, with no reason to continue: stopped. Tamsulosin 0.4 mg at bedtime: continued; no drop in BP on standing. Capillary glucose checks, started in hospital, stopped: on metformin alone, they don’t change care. Antibiotic course complete.
Discharge bloodwork: white count 8.9, down from 15.2 on admission; hemoglobin 11.8 g/dL (118 g/L); creatinine 1.1 mg/dL (98 µmol/L), his baseline. Chest X-ray in hospital: right lower lobe consolidation; no repeat needed while he keeps improving. Falls: none since return. Nursing reassessed his fall risk on his return: bed kept low, call bell and walker within reach, non-slip socks. Pressure injury: stage 2 on the sacrum, as above; foam dressing, turned every 2 hours in bed, pressure-redistributing mattress and wheelchair cushion in place, and his pressure injury risk score updated by nursing. No restraints.
84-year-old man with a past stroke and dysphagia, recovering from aspiration pneumonia: improving, but frailer than before. Pneumonia: antibiotics complete, chest better; watch for a return. Dysphagia: follow the speech-language pathologist’s plan; tooth brushing twice daily and dentures cleaned, since oral care lowers the risk of another pneumonia; dental visit to reline the loose denture. Weight loss of 5.3% in 4 weeks: dietitian referral, a high-energy supplement thickened to mildly thick between meals, and weekly weights. Sacral pressure injury: plan as above, measured weekly. Deconditioning: physiotherapy for transfers and walking, aiming for his 15 m baseline. Diabetes: metformin reduced and glucose checks stopped, as above.
Met with him and his daughter, his named decision-maker, for 25 minutes. He was capable of this decision: he described his illness, the choices, and what each would mean for him. He called the hospital stay “awful” and does not want to go back for another pneumonia, or to have CPR. His goals: stay in the home, keep eating food he enjoys, and walk to the dining room again. Decisions: do not resuscitate; treat a future pneumonia in the home with antibiotics by mouth, oxygen, and fluids; transfer to hospital only for a fracture or symptoms that can’t be managed here. No feeding tube: he accepts the risk of aspiration to keep eating by mouth on his modified diet. His daughter supports his choices. Recorded on the home’s level-of-care form. Charge nurse, dietitian, physiotherapist, and speech-language pathologist updated.
Code status: do not resuscitate; treat in the home; transfer only for a fracture or symptoms that can’t be managed here. Stop pantoprazole. Metformin 500 mg twice daily with meals. Stop capillary glucose checks. Minced and moist diet, mildly thick fluids, upright and supervised for meals and 30 minutes after. Brush teeth and clean dentures twice daily; dental referral for a reline. High-energy supplement, thickened to mildly thick, twice daily between meals. Dietitian and physiotherapy referrals. Weekly weights for 4 weeks. Sacral wound: foam dressing changed every 3 days and as needed; measure weekly. Call for a temperature above 37.8 °C (100 °F), RR above 24, SpO2 below 92%, a new or worse cough with fluids, or eating less than a quarter of his meals for 2 days. Review in 2 weeks, with his weights and the wound.
Why you are seeing the resident today, and what is usual for them. A change can only be judged against a baseline.
Avoid: “Seen at nurse’s request.” Write what the nurse saw, and how it differs from the resident’s usual self.
What nursing, care aides, the resident, and family report, and the numbers the home tracks between your visits. In long-term care, trends over weeks often say more than one day’s values.
Avoid: “Eating well” or “drinking OK.” Use the meal and fluid records: the share of meals eaten and mL a day.
A focused exam tied to the concern, with cognition, skin, and mobility checked against the last visit.
Avoid: “No acute distress.” In a resident with dementia, the useful findings are inattention, drowsiness, and a change in how they move.
What is actually given, from the medication administration record, or MAR, and a decision on each medicine that adds risk. Many of a resident’s problems start here, and many end here.
Avoid: Reading the order list but not the MAR. Refusals, held doses, and nightly PRN sedatives only show up on the MAR.
Labs and tests since the last visit, and the safety events the home tracks: falls, pressure injuries, infections, and restraints.
Avoid: Writing “UTI” on a positive dipstick. Record the urinary symptoms and fever, or their absence, and the decision that follows.
How the resident compares with their baseline, and a plan for each problem.
Avoid: A list of diagnoses with no plan. Each problem needs an action, even when the action is to watch.
What matters to the resident, the code status and transfer plan that follow from it, and who you told.
Avoid: Keeping the code status from admission after a hospital stay or a steady decline. Revisit it, and record who took part.
The orders, what nursing should watch, and when to call. Night staff act on this section.
Avoid: “Monitor closely.” Say what to check, how often, and what result means a call.
Many residents have bacteria in their urine without infection. Confusion with a positive urine test, and no urinary symptoms or fever, isn’t a reason for an antibiotic. Look for dehydration, constipation, pain, and new medicines, and write why you didn’t treat.
“More confused” only means something next to what is usual for this resident. Record their usual orientation, mobility, and eating, from the care plan or the staff who know them.
Medicines started for a hospital problem, such as a stomach protector or a sleeping pill, often carry on with no reason. Check each one against the list from before admission, and stop what isn’t needed.
One weight hides a trend. Compare it with the last few months; a loss of 5% in a month or 10% in 6 months needs a cause and a plan.
A hospital stay, a fall with injury, or a steady decline is the time to revisit resuscitation and transfer wishes. Record who took part and what changed, and update the order.
Vero Scribe writes the progress note in your template from the visit, with the resident’s or decision-maker’s consent, or from your dictation afterward. You review and edit every section, then copy it into the home’s record or export it to Word or PDF. Vero works in 60+ languages.
Start with why you are seeing the resident and their usual baseline. Record the nursing and care aide reports, vital signs, weight trend, intake, bowels and bladder, and sleep and behavior. Then add a focused exam, a review of the medication administration record, results and safety events, a plan for each problem, goals of care, who you spoke with, and the orders with when to call.
Not on those findings alone. Many residents have bacteria in their urine without infection. Without fever, pain or burning on passing urine, new frequency or urgency, flank or suprapubic pain, or other signs of infection, look for other causes such as dehydration, constipation, pain, and new medicines, and watch closely. Write your reasons, and the signs that would change the plan.
Check the discharge medicines against the list from before admission, and stop what was only for the hospital stay. Compare weight, swallowing, skin, mobility, and cognition with the old baseline, look for pending results and follow-up, and revisit goals of care and code status with the resident or their decision-maker.
A comprehensive geriatric assessment is a full review of function, cognition, mood, medicines, and social needs, usually at admission or a turning point. A nursing home progress note records one visit, focused on why you came and what changed since the last one, and it carries the plan from the assessment forward.
Yes. Copy it, or download it as a Word or text file. No account needed.
Every domain of an older adult’s health in one assessment: medicines, function, falls, cognition, mood, nutrition, frailty, support, and a plan per problem.
Complex visit notes, care plans, and family updates, drafted for your review.
Visit notes and care-team handoffs, drafted for your review.
A six-step checklist for comparing medicine lists after a hospital stay.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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