How to Create a Nursing Progress Note
1- To start a Nursing Note you have to access the Patient's Chart Face from the Chartroom after searching the patient and selecting the name.
As you access the Chart Face, go to the notes options and select the Nursing option marked in red.
You are now in the "NURSING PROGRESS NOTE":
2- Breakdown of the Sections in a Nursing Note:
A- Just a Brief Clinical Note 
Clicking the Just a Brief Clinical Note button will add a subtitle to the yellow field. You are able to add a brief note for the patient.
B- Symptoms/Behavior
Next, let’s move on to Symptoms/Behavior. Simply click "Denies Symptom" If the patient doesn't have a specific symptom, otherwise select the associated "See list" button to input symptom-specific sentences into the body of your record. Remember to work from top to bottom of each list’s shrub to capture data in the most logical fashion.
In the example below:
Our patient doesn’t Deny Depression, so we click See list to the right of Denies Depression in the Symptoms list. The screen that appears next is called a “shrub.”
We click Depression still reported from the first column of the shrub. Next, we click Frequency and Duration from the first column and our shrub branches to display a second column. We choose Episodic and then the frequency as Daily and that the Mood lasts for hours. Each time you click an option on the shrub, the program inserts a corresponding sentence into your narrative (see screenshot below).
C- Behavior
The Behavior button can be used to document a wide variety of divergent behaviors. We have clicked the Behavior See list button and, from the buttons in the left column, chosen to record that our patient has Regular Medication Compliance and that she is Irregular in Participation in Activities. Click the Back button to return to the NURSING PROGRESS NOTE.
D- Somatic Symptoms
In the Somatic Symptoms window, the Cough and Weight Loss buttons are pressed. Click the Back button.
E- Enter Test Results:
The enter... Test Results button will bring you to the Test Results window. This is where you can document tests and results.
1. Click the New button.
2. Choose the type of test.
3. Choose the test name.
4. Choose the value.
5. Verify the date performed (change by clicking the calendar icon).
6. Choose the Lab/Organization performing test. If the name is not in the dropdown menu, you are able to free text type in the name.
7. Click the Save button.
8. Once saved, the test is saved in the right column.
Click the Back button. The test results will show in the yellow field.
F- Enter Drug Reactions
We click on the enter... Drug Reactions button to document a variety of side eects associated with medications. Click the Drug Reactions button to document any allergies that the patient may have. If no adverse drug reactions are reported, you can click on None. Once done documenting, don't forget to click Save and then Back button.
Once Saved the list will show in the yellow field.
G-Review Of Systems:
Click the do a... Review Of Systems button to document the review of systems. Within the ROS window, you are able to choose all normal or document per system if there is an abnormality using the shrubs. Click the Back button when done.
H- Nursing Assessments
Click on the do... Nursing Assessments button to enter the Nursing Assessments window. An example of each button is seen below. Use the shrubs to enter documentation for each nursing assessment.
I- Medical History
By clicking to go to... Medical History button, you enter the MEDICAL HISTORY window. You can enter a medical history or edit an existing one. Click the Back button to return to the Nursing Progress Note.
J- Mental Status Exam
Let’s work our way down Column 2. Hitting the Normal button will insert a normal mental status exam status. Clicking the See list button will take us to the Mental Status Exam page.
Let's start by building an opening sentence using the Appearance buttons. We can choose from the array of buttons in the top left field. After, you go down to each section in column 1 and select from the buttons associated or "See list" for more options. The right direction is to move from Appearance all the way down to Suicidality and then move to the second column and start from Homicidal Ideas all the way to Drug Withdrawal.
K- Vital Signs
If you did not document the vital signs in the Mental Status Exam area, click on the Vital Signs button to enter the Constitutional Exam window. Blood pressure, pulse, respirations and height, and weight to achieve calculated BMI. FBS, LDL, GAF, and waist measurements are entered with a click. If vital signs are not taken, you can click the Not Taken button.
L- Pain
By clicking the See Shrub button, the PAIN window will open. When you have selected content or added content, click the Back button to return to the work area.
M- Rating Scales
Click on Rating Scales button to enter test scores from psychologic testing.
N- AIMS
Push the AIMS button to document the Abnormal Involuntary Movement Scale. From here you can print, including the AIMS exam in the Mental Status Exam section of the note, mark all normal, and set due date.
O- Neuro for Nurses
Clicking the Neuro for Nurses button will open to the NEURO FOR NURSES window. This is where you can document the neurological assessment.
P- Physical Exam
Clicking the Physical Exam button will open to the PHYSICAL EXAM window. Once documented, click the Back button.
Q- Restraints and Seclusion
You can document the need for restraints and/or seclusion from the Restraints and Seclusion button. This will bring you to the RESTRAINTS AND SECLUSION window.
R- Nursing Interventions
By clicking the Nursing Interventions button, you will be brought to the NURSING INTERVENTIONS window.
S- Clinical Order Sheet
The Clinical Order Sheet button will bring you to the Clinical Order Sheet. This is an area where you can document orders, protocols, labs, and imaging. This is a great inpatient tool.
T- Medication Reconciliation
Medication Reconciliation is only performed at the intake/transfer of care. For normal progress notes please use the normal Medication Entry screen and choose a verb to Start, Stop or say Ext Provider Rx. From this area, you can add medications, allergies, diagnosis, and medications at discharge. A medication reconciliation note is created when the Confirm button on the right is pushed.
U- Indicate Level of Care Needed
Clicking the Indicate level of care needed button will bring you to the LEVEL OF CARE window. Using the shrubs, you can document the level of care for the patient.
V- Instructions /Recommendations
Select the Instructions/Recommendations button to see choices built into the program. The buttons on the left side of the screen are pre-programmed and offer options appropriate to both inpatient and outpatient settings.
W- Link to Treatment Plan
If you have a treatment plan created already you can link the treatment plan to the progress note. Click on the Link to Treatment Plan button. Choose the treatment plan under "This Note references Treatment Plan." Select the problem under "Select Problem."
X- Discharge Planning
Click the Discharge Planning button to go to the D/C PLANNING window. Use the shrubs to populate the yellow eld. You can also free text into the eld.
Y- Info to Include:
- Notes/Risk Factors included in PN: Notes and risk factors are cleaned from the information you input into the report via the shrubs. This area is also able to be typed in. This will show on the patient's Chart Face.
- Include Medications in The Note? Decide if you want to include the medications in the note.
- Enter VO Meds: Patient Medications are listed by clicking the Enter VO Meds button. The patient medications are brought forward from the previous note and the date of the most recent change is recorded.
- Medical History included in PN:
The Medical History, which is created by a complete evaluation, is shown in the bottom middle. You can decide if you want it in the report or not by the radio buttons.
Z- Service Codes
The Code is where you can enter your billing codes, # of units, modifiers, charges, etc. for this encounter. Click on the Enter button for the popup window to populate.
3- After Adding all the information to the note, it is time to Compile the Note
It is VERY IMPORTANT that you compile your Progress Note to save any changes you made to it. You may always compile your note to save it, then come back and work on it later. When ready, finish the note by clicking the Compile this Note button.
4- Once you compile your note, you will be taken to the Preview Compiled Note Screen. As you can see, there are a number of options on the right. Most are self-explanatory, but you should take note of the spell check button, just under the red text in the screenshot above, which will check your finished note for spelling errors.
5- If you are enabled for electronic signature, you’ll have the option to electronically sign and lock the version of this note that you see on the left by clicking the button on the electronic signature area of the Preview Compiled Note screen. If you are not enabled for electronic signature, please visit Electronic Signature knowledge base article. https://icanotesllc.zohodesk.com/portal/en/kb/articles/requesting-electronic-signature
6- Finding the Compiled Note, you will be able to find the compiled note from the Chart Face in the notes section.
For a video webinar, please see our Clinical Notes for Nurses and Caseworkers webinar.
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