NURSING 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]