Medical Surgical/ General Surgical Nursing Note

Nursing notes or addendums are traditionally free text, but this template is designed to create a nursing note. This in NOT an assessment note. The general flow of this note is: initial impression of the patient, acute changes during shift, nursing interventions, plan of care going forward, and nursing safety precautions.

[comment memo="Intro"]


received pt at [text name="variable_1" default="time"]. 
[select name="variable_111" value="FULL code.| DNR.|DNR/DNI."] Pt alert to [select name="Orientation" value="person, place, time and situation|person, place, and time| person and time|person and place|person only"]. Pt [select name="Presentation" value="pleasant and cooperative with care|uncooperative with care|agitated|sleeping|difficult to arouse|obtunded"] upon initial rounding. 

[comment memo="opening statements"]
[checkbox name="variable_1" value="-Assessment complete|-Assessment and med pass complete|-Vital signs stable|-Telemetry monitored|-EEG monitored|-NG tube|-PEG tube|- Tracheostomy|-Chest tube|-Foley catheter|-Suprapubic catheter|-Rectal tube|-Surgical drain|-Wound Vac|-NPO with meds|-NPO w/o meds|-Fluid restriction|-Intake and Output|-Strict Intake and Output|-Dietary restrictions|-Pt on isolation|-Neuro checks|-Restraints|-1:1 observation|-Post-op|-Post-transfusion|-On ABX|-CIWA|-Palliative|-Hospice|-Considering leaving AMA"][conditional field="variable_1" condition="(variable_1).is('-Assessment complete')"][textarea default="Assessment complete. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Assessment and med pass complete')"][textarea default="Assessment and med pass complete. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Vital signs stable')"][textarea default="Vital signs stable. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Telemetry monitored')"][textarea default="Telemetry monitored. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-EEG monitored')"][textarea default="EEG monitored. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-NG tube')"][textarea default="NG tube. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-PEG tube')"][textarea default="PEG tube. "][/conditional][conditional field="variable_1" condition="(variable_1).is('- Tracheostomy')"][textarea default="Tracheostomy. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Chest tube')"][textarea default="Chest tube. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Foley catheter')"][textarea default="Foley catheter. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Suprapubic catheter')"][textarea default="Suprapubic catheter. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Rectal tube')"][textarea default="Rectal tube in place, patent with no leakage detected. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Surgical drain')"][textarea default="Surgical drain. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Wound Vac')"][textarea default="Wound Vac. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-NPO with meds')"][textarea default="NPO with meds. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-NPO w/o meds')"][textarea default="NPO w/o meds. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Fluid restriction')"][textarea default="Fluid restriction. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Intake and Output')"][textarea default="Intake and Output. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Strict Intake and Output')"][textarea default="Strict Intake and Output. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Dietary restrictions')"][textarea default="Dietary restrictions. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Pt on isolation')"][textarea default="Pt on isolation. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Neuro checks')"][textarea default="Neuro checks. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Restraints')"][textarea default="Restraints. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-1:1 observation')"][textarea default="1:1 observation. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Post-op')"][textarea default="Post-op. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Post-transfusion')"][textarea default="Post-transfusion. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-On ABX')"][textarea default="On antibiotics with no adverse reactions noted. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-CIWA')"][textarea default="On CIWA protocol. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Palliative')"][textarea default="Palliative. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Hospice')"][textarea default="Hospice. "][/conditional][conditional field="variable_1" condition="(variable_1).is('-Considering leaving AMA')"][textarea default="Patient is considering leaving AMA. "][/conditional]
[comment memo="complaints, changes in condition, acute events (If any) USE OLDCARTS"]
[checkbox name="variable_3" value="-No complaints throughout shift|-pt asymptomatic|-pt symptomatic|-No complaints of pain|-Baseline pain|-New pain|-Worsening pain|-pt declining|-pt refusing care|-Change in mentation|-Dementia|-Delirium|-Hallucinations|-Impulsiveness|-Changes in sensory perception|-Nausea|-Dizziness|-Diaphoretic|-Diarrhea|-Change in vital signs|-New heart abnormality|-Changes in blood sugar|-Shortness of breath|-New cough|-New breathing alteration|-Decreasing oxygen saturation|-Increase in secretions|-Shift in CBC/BMP|-New positive lab result|-Abnormal imaging|-Signs of infection|-Concerning CMS assessment|-Bleeding|-Tremors|-Seizure-like activity|-Change in urination|-Change in bowel habits|-Change in appetite|-New alteration in skin|-New edema|- Fall|-Withdrawal symptoms|-Suicidal ideation|-Homicidal ideation|-Suspected abuse|-Adverse reaction to medication|-Rapid Response initialized|-Code initialized|-Provider aware|-Charge aware|-Family notified|-New orders placed|-Consult placed|-No new interventions, continue to monitor|-Incident report completed"][conditional field="variable_3" condition="(variable_3).is('-No complaints throughout shift')"][textarea default="No complaints throughout shift. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-pt asymptomatic')"][textarea default="pt asymptomatic. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-pt symptomatic')"][textarea default="pt symptomatic. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-No complaints of pain')"][textarea default="No complaints of pain. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Baseline pain')"][textarea default="Patient at baseline pain level. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-New pain')"][textarea default="New pain. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Worsening pain')"][textarea default="Worsening pain. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-pt declining')"][textarea default="pt declining. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-pt refusing care')"][textarea default="pt refusing care. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Change in mentation')"][textarea default="Change in mentation. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Dementia')"][textarea default="Dementia. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Delirium')"][textarea default="Delirium. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Hallucinations')"][textarea default="Hallucinations. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Impulsiveness')"][textarea default="Impulsiveness. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Changes in sensory perception')"][textarea default="Changes in sensory perception. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Nausea')"][textarea default="Nausea. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Dizziness')"][textarea default="Dizziness. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Diarrhea')"][textarea default="pt had diarrhea during shift. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Diaphoretic')"][textarea default="Diaphoretic. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Change in vital signs')"][textarea default="Change in vital signs. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-New heart abnormality')"][textarea default="New heart abnormality. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Changes in blood sugar')"][textarea default="Changes in blood sugar. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Shortness of breath')"][textarea default="Shortness of breath. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-New cough')"][textarea default="New cough. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-New breathing alteration')"][textarea default="New breathing alteration. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Decreasing oxygen saturation')"][textarea default="Decreasing oxygen saturation. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Increase in secretions')"][textarea default="Increase in secretions. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Shift in CBC/BMP')"][textarea default="Shift in CBC/BMP. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-New positive lab result')"][textarea default="New positive lab result. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Abnormal imaging')"][textarea default="Abnormal imaging. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Signs of infection')"][textarea default="Signs of infection. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Concerning CMS assessment')"][textarea default="Concerning CMS assessment. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Bleeding')"][textarea default="Bleeding. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Tremors')"][textarea default="Tremors. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Seizure-like activity')"][textarea default="Seizure-like activity. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Change in urination')"][textarea default="Change in urination. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Change in bowel habits')"][textarea default="Change in bowel habits. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Change in appetite')"][textarea default="Change in appetite. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-New alteration in skin')"][textarea default="New alteration in skin. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-New edema')"][textarea default="New edema. "][/conditional][conditional field="New edema" condition="(variable_3).is('- Fall')"][textarea default="Pt sustained a fall. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Withdrawal symptoms')"][textarea default="Withdrawal symptoms. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Suicidal ideation')"][textarea default="Suicidal ideation. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Homicidal ideation')"][textarea default="Homicidal ideation. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Suspected abuse')"][textarea default="Suspected abuse. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Adverse reaction to medication')"][textarea default="Adverse reaction to medication. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Rapid Response initialized')"][textarea default="Rapid Response initialized. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Code initialized')"][textarea default="Code initialized. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Provider aware')"][textarea default="Provider aware. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Charge aware')"][textarea default="Charge aware. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Family notified')"][textarea default="Family notified. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-New orders placed')"][textarea default="New orders placed. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Consult placed')"][textarea default="Consult placed. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-No new interventions, continue to monitor')"][textarea default="No new interventions, continue to monitor. "][/conditional][conditional field="variable_3" condition="(variable_3).is('-Incident report completed')"][textarea default="Incident report completed. "][/conditional]
[comment memo="Physical care provided"]
[checkbox name="variable_4" value="-Re-assessed pt|-Provided resuscitative measures|-Vital signs taken|-Probable causes reviewed|-EKG obtained|-Blood sugar obtained|-pt bladder scanned|-pt catheterized|-Airway maintained|-Titrated oxygen|-Provided PRN medication to good effect|-PRN medications ineffective|-Fluids running|-Secondary medications running|-IV flushed|-Saline locked|-Heparin locked|-Dressing clean, dry, and intact|-Dressing changed|-Wound care provided|-Pre-medicated prior to wound care|-Provided nutrition|-Ambulated pt|-Turned and repositioned|-Applied anti-embolism measures|-Increased frequency of rounding|-pt moved closer to nurses station"][conditional field="variable_4" condition="(variable_4).is('-Re-assessed pt')"][textarea default="Re-assessed pt. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Provided resuscitative measures')"][textarea default="Provided resuscitative measures. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Vital signs taken')"][textarea default="Vital signs taken. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Probable causes reviewed')"][textarea default="Probable causes reviewed. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-EKG obtained')"][textarea default="EKG obtained. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Blood sugar obtained')"][textarea default="Blood sugar obtained. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-pt bladder scanned')"][textarea default="pt bladder scanned. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-pt catheterized')"][textarea default="pt catheterized. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Airway maintained')"][textarea default="Airway maintained. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Titrated oxygen')"][textarea default="Titrated oxygen. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Provided PRN medication to good effect')"][textarea default="Provided PRN medication to good effect. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-PRN medications ineffective')"][textarea default="PRN medications ineffective. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Fluids running')"][textarea default="Fluids running. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Secondary medications running')"][textarea default="Secondary medications running. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-IV flushed')"][textarea default="IV flushed. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Saline locked')"][textarea default="Saline locked. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Heparin locked')"][textarea default="Heparin locked. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Dressing clean, dry, and intact')"][textarea default="Dressing clean, dry, and intact. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Dressing changed')"][textarea default="Dressing changed. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Wound care provided')"][textarea default="Wound care provided. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Pre-medicated prior to wound care')"][textarea default="Pre-medicated prior to wound care. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Provided nutrition')"][textarea default="Provided nutrition. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Ambulated pt')"][textarea default="Ambulated pt. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Turned and repositioned')"][textarea default="Turned and repositioned. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Applied anti-embolism measures')"][textarea default="Applied anti-embolism measures. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-Increased frequency of rounding')"][textarea default="Increased frequency of rounding. "][/conditional][conditional field="variable_4" condition="(variable_4).is('-pt moved closer to nurses station')"][textarea default="pt moved closer to nurses station. "][/conditional]
[comment memo="Emotional care provided"]
[checkbox name="variable_42" value="-Discussed plan of care with pt|-Involved family in discussions|-Discussed course of hospitalization|-Provided support and comfort|-Provided redirection|-Encouraged participation in care|-Explored wishes and values|-Chaplin consulted|-Provider to discuss POLST|-Provider to discuss advance directive"][conditional field="variable_42" condition="(variable_42).is('-Discussed plan of care with pt')"][textarea default="Discussed plan of care with pt. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Involved family in discussions')"][textarea default="Involved family in discussions. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Discussed course of hospitalization')"][textarea default="Discussed course of hospitalization. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Provided support and comfort')"][textarea default="Provided support and comfort. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Provided redirection')"][textarea default="Provided redirection. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Encouraged participation in care')"][textarea default="Encouraged participation in care. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Explored wishes and values')"][textarea default="Explored wishes and values. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Chaplin consulted')"][textarea default="Chaplin consulted. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Provider to discuss POLST')"][textarea default="Provider to discuss POLST. "][/conditional][conditional field="variable_42" condition="(variable_42).is('-Provider to discuss advance directive')"][textarea default="Provider to discuss advance directive. "][/conditional]
[comment memo="Progress in care"][checkbox name="variable_2" value="-Awaiting procedure|-pt working with PT/OT|-continuing medication course"] [conditional field="variable_2" condition="(variable_2).is('-Awaiting procedure')"][textarea default="Awaiting procedure. "][/conditional][conditional field="variable_2" condition="(variable_2).is('-pt working with PT/OT')"][textarea default="pt working with PT/OT. "][/conditional][conditional field="variable_2" condition="(variable_2).is('-continuing medication course')"][textarea default="continuing medication course. "][/conditional]
[comment memo="Plan"]
[checkbox name="Q3" value="-Discharge today|-Discharge tomorrow|-Awaiting bed|-Pending placement|-Homeless|-Pending medical clearance|-Pt undergoing rehabilitation/ therapy|-Higher level of care required|-Difficult discharge"][conditional field="Q3" condition="(Q3).is('-Discharge today')"][textarea default="Discharge today. "][/conditional][conditional field="Q3" condition="(Q3).is('-Discharge tomorrow')"][textarea default="Discharge tomorrow. "][/conditional][conditional field="Q3" condition="(Q3).is('-Awaiting bed')"][textarea default="Awaiting bed. "][/conditional][conditional field="Q3" condition="(Q3).is('-Pending placement')"][textarea default="Pending placement. "][/conditional][conditional field="Q3" condition="(Q3).is('-Homeless')"][textarea default="Homeless. "][/conditional][conditional field="Q3" condition="(Q3).is('-Pending medical clearance')"][textarea default="Pending medical clearance. "][/conditional][conditional field="Q3" condition="(Q3).is('-Pt undergoing rehabilitation/ therapy')"][textarea default="Pt undergoing rehabilitation/ therapy. "][/conditional][conditional field="Q3" condition="(Q3).is('-Higher level of care required')"][textarea default="Higher level of care required. "][/conditional][conditional field="Q3" condition="(Q3).is('-Difficult discharge')"][textarea default="Difficult discharge. "][/conditional]

[comment memo="Needs prior to discharge"]
[checkbox name="Q2" value="-Meet with provider prior to discharge|-Pharmacy concerns|-Dietary concerns|-Financial concerns|-Follow up care|-Home oxygen|-Prosthetics/crutches/immobilizers|-Equipment|-Dressing supplies|-Transport|-Home health|-Will review vaccination status|-Will coordinate with interprofessional team"][conditional field="Q2" condition="(Q2).is('-Meet with provider prior to discharge')"][textarea default="Meet with provider prior to discharge. "][/conditional][conditional field="Q2" condition="(Q2).is('-Pharmacy concerns')"][textarea default="Pharmacy concerns. "][/conditional][conditional field="Q2" condition="(Q2).is('-Dietary concerns')"][textarea default="Dietary concerns. "][/conditional][conditional field="Q2" condition="(Q2).is('-Financial concerns')"][textarea default="Financial concerns. "][/conditional][conditional field="Q2" condition="(Q2).is('-Follow up care')"][textarea default="Follow up care. "][/conditional][conditional field="Q2" condition="(Q2).is('-Home oxygen')"][textarea default="Home oxygen. "][/conditional][conditional field="Q2" condition="(Q2).is('-Prosthetics/crutches/immobilizers')"][textarea default="Prosthetics/crutches/immobilizers. "][/conditional][conditional field="Q2" condition="(Q2).is('-Equipment')"][textarea default="Equipment. "][/conditional][conditional field="Q2" condition="(Q2).is('-Dressing supplies')"][textarea default="Dressing supplies. "][/conditional][conditional field="Q2" condition="(Q2).is('-Transport')"][textarea default="Transport. "][/conditional][conditional field="Q2" condition="(Q2).is('-Home health')"][textarea default="Home health. "][/conditional][conditional field="Q2" condition="(Q2).is('-Will review vaccination status')"][textarea default="Will review vaccination status. "][/conditional][conditional field="Q2" condition="(Q2).is('-Will coordinate with interprofessional team')"][textarea default="Will coordinate with interprofessional team. "][/conditional]
[comment memo="Closing statements"]
[checkbox name="Q1" value="-No acute events during shift|-Took all medications|-No adverse effects from medications noted|-Hourly rounding in effect|-Hourly rounding completed|-Family in room|-Provided education|-Pressure injury prevention measures in place|-Fall precautions in place|-Seizure precautions in place|-All pt needs met|-Will continue to monitor|-Will provide report to oncoming shift|-Will provide report to receiving nurse|-Report given|-Call light and personal items within reach|-WanderGuard on|-Bed alarm on|-Chair alarm on|-Suction at bedside|-Tracheostomy supplies at bedside|-IV discontinued|-pt prepared for transfer|-pt transferred|-pt prepared for discharge|-Pt discharged"][conditional field="Q1" condition="(Q1).is('-No acute events during shift')"][textarea default="No acute events during shift. "][/conditional][conditional field="Q1" condition="(Q1).is('-Took all medications')"][textarea default="Took all medications. "][/conditional][conditional field="Q1" condition="(Q1).is('-No adverse effects from medications noted')"][textarea default="No adverse effects from medications noted. "][/conditional][conditional field="Q1" condition="(Q1).is('-Hourly rounding in effect')"][textarea default="Hourly rounding in effect. "][/conditional][conditional field="Q1" condition="(Q1).is('-Hourly rounding completed')"][textarea default="Hourly rounding completed. "][/conditional][conditional field="Q1" condition="(Q1).is('-Family in room')"][textarea default="Family in room. "][/conditional][conditional field="Q1" condition="(Q1).is('-Provided education')"][textarea default="Provided education. "][/conditional][conditional field="Q1" condition="(Q1).is('-Pressure injury prevention measures in place')"][textarea default="Pressure injury prevention measures in place. "][/conditional][conditional field="Q1" condition="(Q1).is('-Fall precautions in place')"][textarea default="Fall precautions in place. "][/conditional][conditional field="Q1" condition="(Q1).is('-Seizure precautions in place')"][textarea default="Seizure precautions in place. "][/conditional][conditional field="Q1" condition="(Q1).is('-All pt needs met')"][textarea default="All pt needs met. "][/conditional][conditional field="Q1" condition="(Q1).is('-Will continue to monitor')"][textarea default="Will continue to monitor. "][/conditional][conditional field="Q1" condition="(Q1).is('-Will provide report to oncoming shift')"][textarea default="Will provide report to oncoming shift. "][/conditional][conditional field="Q1" condition="(Q1).is('-Will provide report to receiving nurse')"][textarea default="Will provide report to receiving nurse. "][/conditional][conditional field="Q1" condition="(Q1).is('-Report given')"][textarea default="Report given. "][/conditional][conditional field="Q1" condition="(Q1).is('-Call light and personal items within reach')"][textarea default="Call light and personal items within reach. "][/conditional][conditional field="Q1" condition="(Q1).is('-WanderGuard on')"][textarea default="WanderGuard on. "][/conditional][conditional field="Q1" condition="(Q1).is('-Bed alarm on')"][textarea default="Bed alarm on. "][/conditional][conditional field="Q1" condition="(Q1).is('-Chair alarm on')"][textarea default="Chair alarm on. "][/conditional][conditional field="Q1" condition="(Q1).is('-Suction at bedside')"][textarea default="Suction at bedside. "][/conditional][conditional field="Q1" condition="(Q1).is('-Tracheostomy supplies at bedside')"][textarea default="Tracheostomy supplies at bedside. "][/conditional][conditional field="Q1" condition="(Q1).is('-IV discontinued')"][textarea default="IV discontinued. "][/conditional][conditional field="Q1" condition="(Q1).is('-pt prepared for transfer')"][textarea default="pt prepared for transfer. "][/conditional][conditional field="Q1" condition="(Q1).is('-pt transferred')"][textarea default="pt transferred. "][/conditional][conditional field="Q1" condition="(Q1).is('-pt prepared for discharge')"][textarea default="pt prepared for discharge. "][/conditional]



[shorthand name="-Assessment complete" value=""]
[shorthand name="-Assessment and med pass complete" value=""]
[shorthand name="-Vital signs stable" value=""]
[shorthand name="-Telemetry monitored" value=""]
[shorthand name="-EEG monitored" value=""]
[shorthand name="-NG tube" value=""]
[shorthand name="-PEG tube" value=""]
[shorthand name="- Tracheostomy" value=""]
[shorthand name="-Chest tube" value=""]
[shorthand name="-Foley catheter" value=""]
[shorthand name="-Suprapubic catheter" value=""]
[shorthand name="-Rectal tube" value=""]
[shorthand name="-Surgical drain" value=""]
[shorthand name="-Wound Vac" value=""]
[shorthand name="-NPO with meds" value=""]
[shorthand name="-NPO w/o meds" value=""]
[shorthand name="-Fluid restriction" value=""]
[shorthand name="-Intake and Output" value=""]
[shorthand name="-Strict Intake and Output" value=""]
[shorthand name="-Dietary restrictions" value=""]
[shorthand name="-Pt on isolation" value=""]
[shorthand name="-Neuro checks" value=""]
[shorthand name="-Restraints" value=""]
[shorthand name="-1:1 observation" value=""]
[shorthand name="-Post-op" value=""]
[shorthand name="-Post-transfusion" value=""]
[shorthand name="-On ABX" value=""]
[shorthand name="-CIWA" value=""]
[shorthand name="-Palliative" value=""]
[shorthand name="-Hospice" value=""]
[shorthand name="-Considering leaving AMA" value=""]

[shorthand name="-No complaints throughout shift" value=""]
[shorthand name="-pt asymptomatic" value=""]
[shorthand name="-pt symptomatic" value=""]
[shorthand name="-No complaints of pain" value=""]
[shorthand name="-Baseline pain" value=""]
[shorthand name="-New pain" value=""]
[shorthand name="-Worsening pain" value=""]
[shorthand name="-pt declining" value=""]
[shorthand name="-pt refusing care" value=""]
[shorthand name="-Change in mentation" value=""]
[shorthand name="-Dementia" value=""]
[shorthand name="-Delirium" value=""]
[shorthand name="-Hallucinations" value=""]
[shorthand name="-Impulsiveness" value=""]
[shorthand name="-Changes in sensory perception" value=""]
[shorthand name="-Nausea" value=""]
[shorthand name="-Dizziness" value=""]
[shorthand name="-Diarrhea" value=""]
[shorthand name="-Diaphoretic" value=""]
[shorthand name="-Change in vital signs" value=""]
[shorthand name="-New heart abnormality" value=""]
[shorthand name="-Changes in blood sugar" value=""]
[shorthand name="-Shortness of breath" value=""]
[shorthand name="-New cough" value=""]
[shorthand name="-New breathing alteration" value=""]
[shorthand name="-Decreasing oxygen saturation" value=""]
[shorthand name="-Increase in secretions" value=""]
[shorthand name="-Shift in CBC/BMP" value=""]
[shorthand name="-New positive lab result" value=""]
[shorthand name="-Abnormal imaging" value=""]
[shorthand name="-Signs of infection" value=""]
[shorthand name="-Concerning CMS assessment" value=""]
[shorthand name="-Bleeding" value=""]
[shorthand name="-Tremors" value=""]
[shorthand name="-Seizure-like activity" value=""]
[shorthand name="-Change in urination" value=""]
[shorthand name="-Change in bowel habits" value=""]
[shorthand name="-Change in appetite" value=""]
[shorthand name="-New alteration in skin" value=""]
[shorthand name="-New edema" value=""]
[shorthand name="- Fall" value=""]
[shorthand name="-Withdrawal symptoms" value=""]
[shorthand name="-Suicidal ideation" value=""]
[shorthand name="-Homicidal ideation" value=""]
[shorthand name="-Suspected abuse" value=""]
[shorthand name="-Adverse reaction to medication" value=""]
[shorthand name="-Rapid Response initialized" value=""]
[shorthand name="-Code initialized" value=""]
[shorthand name="-Provider aware" value=""]
[shorthand name="-Charge aware" value=""]
[shorthand name="-Family notified" value=""]
[shorthand name="-New orders placed" value=""]
[shorthand name="-Consult placed" value=""]
[shorthand name="-No new interventions, continue to monitor" value=""]
[shorthand name="-Incident report completed" value=""]

[shorthand name="-Re-assessed pt" value=""]
[shorthand name="-Provided resuscitative measures" value=""]
[shorthand name="-Vital signs taken" value=""]
[shorthand name="-Probable causes reviewed" value=""]
[shorthand name="-EKG obtained" value=""]
[shorthand name="-Blood sugar obtained" value=""]
[shorthand name="-pt bladder scanned" value=""]
[shorthand name="-pt catheterized" value=""]
[shorthand name="-Airway maintained" value=""]
[shorthand name="-Titrated oxygen" value=""]
[shorthand name="-Provided PRN medication to good effect" value=""]
[shorthand name="-PRN medications ineffective" value=""]
[shorthand name="-Fluids running" value=""]
[shorthand name="-Secondary medications running" value=""]
[shorthand name="-IV flushed" value=""]
[shorthand name="-Saline locked" value=""]
[shorthand name="-Heparin locked" value=""]
[shorthand name="-Dressing clean, dry, and intact" value=""]
[shorthand name="-Dressing changed" value=""]
[shorthand name="-Wound care provided" value=""]
[shorthand name="-Pre-medicated prior to wound care" value=""]
[shorthand name="-Ambulated pt" value=""]
[shorthand name="-Turned and repositioned" value=""]
[shorthand name="-Provided nutrition" value=""]
[shorthand name="-Applied anti-embolism measures" value=""]
[shorthand name="-Increased frequency of rounding" value=""]
[shorthand name="-pt moved closer to nurses station" value=""]

[shorthand name="-Discussed plan of care with pt" value=""]
[shorthand name="-Involved family in discussions" value=""]
[shorthand name="-Discussed course of hospitalization" value=""]
[shorthand name="-Provided support and comfort" value=""]
[shorthand name="-Provided redirection" value=""]
[shorthand name="-Encouraged participation in care" value=""]
[shorthand name="-Explored wishes and values" value=""]
[shorthand name="-Chaplin consulted" value=""]
[shorthand name="-Provider to discuss POLST" value=""]
[shorthand name="-Provider to discuss advance directive" value=""]

[shorthand name="-Awaiting procedure" value=""]
[shorthand name="-pt working with PT/OT" value=""]
[shorthand name="-continuing medication course" value=""]

[shorthand name="-Discharge today" value=""]
[shorthand name="-Discharge tomorrow" value=""]
[shorthand name="-Awaiting bed" value=""]
[shorthand name="-Pending placement" value=""]
[shorthand name="-Homeless" value=""]
[shorthand name="-Pending medical clearance" value=""]
[shorthand name="-Pt undergoing rehabilitation/ therapy" value=""]
[shorthand name="-Higher level of care required" value=""]
[shorthand name="-Difficult discharge" value=""]

[shorthand name="-Meet with provider prior to discharge" value=""]
[shorthand name="-Pharmacy concerns" value=""]
[shorthand name="-Dietary concerns" value=""]
[shorthand name="-Financial concerns" value=""]
[shorthand name="-Follow up care" value=""]
[shorthand name="-Home oxygen" value=""]
[shorthand name="-Prosthetics/crutches/immobilizers" value=""]
[shorthand name="-Equipment" value=""]
[shorthand name="-Dressing supplies" value=""]
[shorthand name="-Transport" value=""]
[shorthand name="-Home health" value=""]
[shorthand name="-Will review vaccination status" value=""]
[shorthand name="-Will coordinate with interprofessional team" value=""]

[shorthand name="-No acute events during shift" value=""]
[shorthand name="-took all medications" value=""]
[shorthand name="-No adverse effects from medications noted" value=""]
[shorthand name="-Hourly rounding in effect" value=""]
[shorthand name="-Hourly rounding completed" value=""]
[shorthand name="-Family in room" value=""]
[shorthand name="-Provided education" value=""]
[shorthand name="-Pressure injury prevention measures in place" value=""]
[shorthand name="-Fall precautions in place" value=""]
[shorthand name="-Seizure precautions in place" value=""]
[shorthand name="-All pt needs met" value=""]
[shorthand name="-Will continue to monitor" value=""]
[shorthand name="-Will provide report to oncoming shift" value=""]
[shorthand name="-Will provide report to receiving nurse" value=""]
[shorthand name="-Report given" value=""]
[shorthand name="-Call light and personal items within reach" value=""]
[shorthand name="-WanderGuard on" value=""]
[shorthand name="-Bed alarm on" value=""]
[shorthand name="-Chair alarm on" value=""]
[shorthand name="-Suction at bedside" value=""]
[shorthand name="-Tracheostomy supplies at bedside" value=""]
[shorthand name="-IV discontinued" value=""]
[shorthand name="-pt prepared for transfer" value=""]
[shorthand name="-pt transferred" value=""]
[shorthand name="-pt prepared for discharge" value=""]
[shorthand name="-Pt discharged" value=""]




[shorthand name="," value=""]

This form uses shorthand, to view it please click View > Edit Markup


Nursing notes or addendums are traditionally free text, but this template is designed to create a nursing note. This in NOT an assessment note. The general flow of this note is: initial impression of the patient, acute changes during shift, nursing interventions, plan of care going forward, and nursing safety precautions.

Intro


received pt at .
Pt alert to . Pt upon initial rounding.

opening statements

complaints, changes in condition, acute events (If any) USE OLDCARTS

Physical care provided

Emotional care provided

Progress in care
Plan


Needs prior to discharge

Closing statements





























































































































































































Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.06, 542 form elements, 61 boilerplate words, 1 text boxes, 173 text areas, 8 checkboxes, 3 drop downs, 9 comments, 173 conditionals, 175 shorthands, 351 total clicks
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