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Discharge Diagnosis*: Make sure this is a diagnosis and not a symptom or sign.
One example is using a SOAP note, where the progress note is organized into Subjective, Objective, Assessment, and Plan sections.
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The progress notes focus on the objectives stated in the nursing care plan. A nursing note is a medical or health record that is made by a nurse that shows an accurate documentation of nursing assessments, changes in patient's conditions, care provided, and related information to support the clinical team to deliver excellent care. The team gains information from your records.
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