Posted: October 20th, 2022

Patient Progress Notes

Patient Progress Notes

Name of Student _______________________
Student Number _______________________
Hospital _______________________________
teacher name ___________________________
Clinical Area ___________________________
Week # ________________________________
Date Submitted ________________________
Mark ___________ /10

Who Can Write My Dissertation or Research Paper? Best Writing Service!

Looking for reliable dissertation help or thesis writing? Our expert team of MPhil and PhD-qualified professionals provides top-notch online assistance for dissertations, research papers, and essays—free from errors, plagiarism, and hidden fees. We select each specialist based on their academic expertise, ensuring high-quality thesis writing and research paper support. Beyond writing, we offer personalized guidance, one-on-one doubt-clearing sessions, and free study resources. Whether you need instant dissertation help or long-term research paper support, our experts are ready to help you succeed.

BIOGRAPHIC DATA Marks Student Marks
Patient Name (initial)

-
Age
Gender
1

Admission Date

Admitting Diagnosis
1

What Are Custom Dissertation and Thesis Writing Services? Just Essays?

Our custom dissertation help and thesis writing services meet your unique requirements. Unlike companies using pre-written content, we craft every dissertation, research paper, or essay from scratch based on your specific instructions and grading rubric. A subject-specialized writer will deliver a well-researched dissertation or thesis tailored just for you. Beyond essays, our academics and scholars offer PowerPoint presentations, cover letters, editing, tutoring, and business reports—comprehensive dissertation help and research paper support for all your academic needs.

Chief Complain

Total Marks 2

Can I Hire Someone for Dissertation Help or Thesis Writing to Score Top Grades?

Completing dissertations or research papers can be overwhelming, but expert dissertation help and thesis writing are smart ways to improve your grades. Our platform connects you with top-rated tutors in education, law, and nursing, offering high-quality research paper support and sample resources. Working with experienced professionals enhances your dissertation or thesis writing, boosting confidence in your coursework—at affordable fees. Sign up today for instant dissertation help, research paper guidance, and stress-free learning!

PRESENT ILLNES Marks Student Marks
P Provoke:
1
Palliative:
1
Q Quality:
1
R Region:
1
Radiation:

S Severity:
1
T Onset:
1
Duration:
1
Frequency:
U Understanding Patient Perception:
1
Total Marks 8

Past history mark St. mark
Medical & surgical 1
medication 1
immunization
Life style 1
Family history
Total 3

Literature Review

Disease pathophysiology
(1 mark) Mark
Clinical manifestations
(1 mark)
Assessment and diagnostic findings
(1 mark)
Medical management
(1 mark)
Nursing management
(1 mark)
Total marks 5

PHYSICAL ASSESSMENT
SYSTEM PATIENT FINDING Marks Student Marks
NEURO LOC □Oriented □Alert □Lethargic □Sedated □Unresponsive
□Respond only to pain □Agitated □Calm □ Cry □Confused 1
GCS Motor…..…. +Verbal…..… +Eye……... =
Other
SKIN Hair □Thick □Thin □Dull □Shiny Color……….. 1
Nail □Flat □Curve □Convex □Clean □ Dirty □brittle Color…………
Skin Integrity □Intact □Dry □ Moist □Wound □Ulcer
Skin Color □Pink/WML □ Pale □Jaundiced □Cyanotic
Skin Temperature □Warm □ Hot □ Cold
Wound/Ulcer □None □Yes
Location………… Size……….. Border………….Depth ………… Stage……..…
Other
CARDIAC Edema □None □ Yes +1 / +2 / +3 / +4 Location ………. 1
Capillary Refill □Normal (1-2 seconds) □ Delayed (>3 seconds)
Heart Sounds □Normal S1/S2 □Abnormal
Arterial Pulses □Strong □Weak □Increased □Pounding □Absent
Rhythm □Regular □ Irregular
Other
RESPIRATORY Breath Sound □Clear □Crackles □Wheezes 1
Cough □Absent □ Productive □ Non productive
Sputum/Secretion Color……….. Consistency: □Thin □Thick
O2 Therapy □None □ O2 @ ...... L/M FIO2 …… % Per:
Other
Gastrointestinal Diet □NPO □ Reg □Clear □Soft 1
Appetite □Good □Fair □Poor □Nausea □Vomiting
Abdomen □Soft □Firm □Distended
Bowel Sounds □Active □Hyperactive □Hypoactive □Absent
Stool □None □Formed □Soft □ Liquid Color……… LBM …../.…../……..
Other
GENITOURINARY Urine □Continent □Incontinent □ Foley Color……….. 1
Other
MUSCLOSKELETAL ROM □Full Limited 1
Abnormality □Absent □Present Location……….
Other
ACTIVITY Activity □Dependent □Independent □Bedrest 1
Hygiene □Clean □ Dirty
Other
SAFETY Patient Safety Needs □Call bell in reach □Bed in Low position
□Breaks on □Side Rails up □ID band on 1
Other
ISOLATION Isolation precaution □Standard □Contact □Airborne □Droplet 1
Other
Lines Invasive Lines Type 1 Site Condition 1

Total Marks 11

Lab investigation and diagnostic test
Name of test Normal range (1) Result (1) Significant (1)

Total marks (3)

Medication (1)
Drug name
Classification Uses
(0.5 mark) Side effects
(0.5 mark) Nursing considerations
(1 mark) Patient/family education
(0.5 mark)
Assess:
Administer:
Perform/provide:
Evaluate:
Total marks (2.5)

Medication (2)
Drug name Classification
Uses
(0.5mark) Side effects
(0.5 mark) Nursing considerations
(1 mark) Patient/family education
(0.5 mark)
Assess:
Administer:
Perform/provide:
Evaluate:
Total marks (2.5)

PRIORITY NURSING PROBLEMS (1)

1. _____________________________________
2. _____________________________________
3. _____________________________________
4. _____________________________________

ACTUAL NURSIING PROCESS Marks Student Marks
Assessment : Subjective data:

1
Objective data:

1
Nursing diagnosis

1
Plan / Goal

1
Interventions (not less than 4 actions)

1. _______________________________________________________
_______________________________________________________
2. _______________________________________________________
_______________________________________________________
3. _______________________________________________________
_______________________________________________________
4. _______________________________________________________
_______________________________________________________
5. _______________________________________________________
_______________________________________________________
2
Evaluation
1
Total Marks
7

POTENTIAL NURSING PROCESS Marks Student Marks
Nursing diagnosis

1
Plan / Goal

1
Interventions (not less than 4 actions)

1. _______________________________________________________
_______________________________________________________
2. _______________________________________________________
_______________________________________________________
3. _______________________________________________________
_______________________________________________________
4. _______________________________________________________
_______________________________________________________
5. _______________________________________________________
_______________________________________________________
2
Evaluation

1
Total Marks
5

SMMARY FOR PROGRESS NOTES:

Student Marks Marks items
2 Biographic Data
8 Present Illness
3 Past history
5 Literature review
11 Physical Assessment
3 Lad investigation and diagnostic test
5 Medication
1 Priority Of Nursing Process
7 Actual Nursing Process
5 Potential Nursing Process
50%5 = 10 Total

Clinical Performance List

Procedure Observe Perform date Preceptor Signature

Name of Student _______________________ Student Number _______________________