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Nurse’s role in writing progress notes, 3.2. Nursing progress report, They…
Nurse’s role in writing progress notes
Observation and Documentation
Recording Nursing Interventions
Nurses document all care actions, such as :
• Medications and treatments given (name, dose, time, route, and effect).
• Respiratory support (oxygen therapy, CPAP, ventilator settings).
• IV therapy (site condition, type of fluids, infusion rates).
• Thermoregulation (incubator use, temperature monitoring).
• Pain management, comfort measures, and positioning.
• Developmental care (kangaroo care, nesting, light/sound reduction).
Assessing and Reporting Infant Response
Nurses assess how the infant responds to care and document :
• Improvements (e.g., increased feed tolerance, stable vitals).
• Deterioration (e.g., apnea, bradycardia, poor perfusion).
Communication with the Healthcare Team
Nurses use progress notes to:
• Share important updates with neonatologists, pediatricians, and other team members.
• Document instructions or updates from doctors.
• Report any multidisciplinary interventions (e.g., physiotherapy, lactation consultation).
Parental Interaction and Education
Nurses record:
• Parental visits and interactions with the infant.
• Education provided to parents (e.g., feeding, hygiene, holding).
• Emotional status and concerns of parents.
• Support offered to families (e.g., counselling, referrals).
Legal and Ethical Documentation
Nurses must ensure they are:
• Accurate and objective: Avoid opinions or assumptions.
• Timely: Write as close to the time of care as possible.
• Legible and professional.
• Confidential: Respect patient and family privacy.
• Written using approved abbreviations and terminology.
Common Formats Used in Neonatal Progress Notes
Nurses may use standardized formats to organize their documentation :
• S – Situation
• B – Background
• A – Assessment
• R – Recommendation
3.2. Nursing progress report
They document:
• Vital signs (e.g., temperature, heart rate, respiratory rate, oxygen saturation).
• Feeding and nutrition (type, volume, tolerance, vomiting, regurgitation).
• Elimination patterns (urine output, stool frequency, color, and consistency.
• Behavioral and neurological signs (alertness, crying, tone, reflexes).
• Skin color and condition (cyanosis, jaundice, rashes, pressure injuries)