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SAMPLE: PSYCHIATRIC NURSE PROGRESS NOTE
Generously Provided By Angel Home Care Services, Inc. – Miami, FL
PATIENT DETAILS DATE EMPLOYEE
LAST NAME
FIRST NAME NUMBER MO. DAY YR. NUMBER INITIALS
HOMEBOUND DUE TO
_______________________________________________________________________
SKILLED NURSING SERVICES
NURSING VISIT CODE
RV – ROUTINE VISIT
EV – EMERGENCY VISIT
OBSERVATIONS / MONITORING
VITAL SIGNS: BP _______ AP _______ REG _______ IRREG _______
TEMP _______ RESPIRATIONS _______
LUNGS: CTA _______ RALES _______ BS _______
PATIENT / FAMILY TEACHINGS
MEDICATION REGIME
ACTION / SIDE EFFECTS OF: ____________________
S/S DISEASE PROCESS OF: ___________________
S/S OF COMPLICATIONS OF: ____________________
EXTRAPYRAMIDAL SYMPTOMS
SAFETY MEASURES
RELAXATION TECHNIQUES
MENTAL STATUS: IMPROVED _____ SAME _____ REGRESSED _____
ALERT CONFUSED DISORIENTED
HALLUCINATIONS / DELUSIONS: PRESENT _____ ABSENT _____
SUICIDAL TENDENCIES: PRESENT _____ ABSENT _____
EXTRAPYRAMIDAL SX: PRESENT _____ ABSENT _____
ORIENTED: TIME _____ PLACE _____ PERSON _____
INSIGHT PT / FAMILY: GOOD _____ FAIR _____ POOR _____
NUTRITION
DIET
PROPER FLUID INTAKE
THERAPY PROVIDED
SUPPORTIVE
REALITY
MOOD / AFFECT: IMPROVED _____ SAME _____ REGRESSED _____
FLAT AGITATED DEPRESSED
ANXIOUS COMBATIVE NEGATIVE
AIDE SUPERVISORY VISIT
COMMUNICATION: IMPROVED _____ SAME _____ REGRESSED _____
SOCIALIZATION: _______________________________________________
SOMATIZATION: _______________________________________________
VENTILATES FEELINGS: GOOD _____ FAIR _____ POOR _____
PATIENT SATISFIED WITH CARE PLAN
AIDE FOLLOWING CARE PLAN
CARE PLAN UPDATED
AIDE NEEDED _____ TIMES PER WEEK
YES
YES
YES
NO
NO
NO
RAPPORT: ____________________________________________________
PATIENT with FAMILY: IMPROVED _____ SAME _____ REGRESSED _____
FAMILY with PATIENT: IMPROVED _____ SAME _____ REGRESSED _____
PATIENT with RN: IMPROVED _____ SAME _____ REGRESSED _____
FAMILY with RN: IMPROVED _____ SAME _____ REGRESSED _____
SPECIFIC MEDICAL TREATMENTS / TEACHINGS
____________________________________________
____________________________________________
NUTRITION STATUS:
APPETITE: IMPROVED _____ SAME _____ DECREASED _____
FLUID INTAKE: IMPROVED _____ SAME _____ DECREASED _____
____________________________________________
____________________________________________
G.I. BOWEL FUNCTIONS: REGULATED _____ IRREGULAR _____
CATHARTIC REQUIRED: YES _____ NO _____
____________________________________________
ADL LEVEL: IMPROVED _____ SAME _____ REGRESSED _____
DRESSING: IMPROVED _____ SAME _____ REGRESSED _____
MOTIVATION: IMPROVED _____ SAME _____ REGRESSED _____
PERSONAL HYGIENE: IMPROVED _____ SAME _____ REGRESSED _____
SLEEPING HABITS: IMPROVED _____ SAME _____ REGRESSED _____
____________________________________________
____________________________________________
____________________________________________
____________________________________________
ASSESSMENT OF PROBLEMS AND RESPONSES:
PLAN:
PHYSICIAN COMMUNICATION:
ADDITIONAL / CHANGE ORDERS:
DISCHARGE PLANNING:
SIGNATURE:
2/5/08