Community Nurse Template

Community Nurse's note (custom)

A professional Community Nurse template for healthcare professionals.

About this template

The Community Nurse's Note template is a comprehensive documentation tool designed for community nurses to record patient assessments and care plans during home visits or community settings. This template includes sections for subjective and objective data, nursing assessments, care plans, interventions, and evaluations. It is ideal for capturing detailed patient information, including vital signs, physical assessments, and patient education. Community nurses can use this template to ensure continuity of care and effective communication with other healthcare team members. This template is particularly useful for managing chronic conditions and coordinating care in community health settings.

Preview template

Patient Information: - Patient Name: John Doe, ID: 123456, Date of Birth: 15 March 1950 - Date and Time of the Nursing Assessment: 1 November 2024, 10:00 AM - Location: Home Visit Subjective: - Reason for visit/admission: Routine check-up and management of chronic conditions - Patient’s description of pain or discomfort: Mild joint pain in knees, intensity 3/10, aching character - Expressed concerns: Concerned about managing medication schedule - Understanding of diagnosis and care needs: Patient and family understand the need for regular monitoring of blood pressure and blood glucose levels Objective: - Vitals: BP 130/85 mmHg, HR 72 bpm, RR 16 breaths/min, Temperature 36.8°C, Oxygen Saturation 98% - Physical assessment findings: General appearance well, skin intact, no edema, clear heart and lung sounds, abdomen soft and non-tender, mobility limited due to knee pain - Results of bedside tests: Blood glucose level 7.2 mmol/L - Review of medical chart: Recent lab results show stable kidney function, no medication changes Assessment: - Nursing diagnosis: Chronic pain related to osteoarthritis, risk for medication non-compliance - Prioritization of patient care needs: Pain management and medication adherence Plan: - Care plan adjustments: Reinforce medication schedule, provide pain management strategies - Scheduled procedures: None for the day - Collaboration: Discuss pain management with primary care physician Interventions: - Administered prescribed analgesics, provided education on medication management - Response to interventions: Patient reported slight relief in knee pain Evaluation: - Evaluation of patient’s response: Patient shows understanding of medication schedule, pain slightly reduced - Changes in patient status: No significant changes Plan for Continuing Care: - Next steps: Continue current medication regimen, follow-up in two weeks, consider referral to physiotherapy for knee pain Additional Notes: - Education provided on home safety and fall prevention - Communication with patient and family: Discussed importance of medication adherence and regular monitoring - Safety concerns: None reported

Patient Information: - [Patient Name, ID, and Date of Birth (mention if available)] - [Date and Time of the Nursing Assessment (mention if available)] - [Location (e.g., department, room number) (mention if available)] Subjective: - [Reason for visit/admission, including patient’s verbalized concerns or symptoms (mention if available)] - [Patient’s description of pain or discomfort (location, intensity on a scale of 0-10, character) (mention only if available)] - [Any expressed concerns about treatment, care, or the healthcare environment (mention only if available)] - [Patient’s and family’s understanding of the diagnosis, treatment plan, and care needs (mention only if available)] Objective: - [Vitals including BP, HR, RR, Temperature, Oxygen Saturation, etc (mention if available)] - [Physical assessment findings, including general appearance, skin integrity, presence of edema, heart and lung sounds, abdominal assessment, mobility status, and any other relevant clinical signs (mention if available)] - [Results of any bedside tests or monitoring (e.g., blood glucose levels, INR for patients on anticoagulants) (mention if available)] - [Review of medical chart for recent lab results, diagnostic tests, orders, and medication changes (mention if available)] Assessment: - [Nursing diagnosis or identified needs based on the subjective and objective data (mention if available)] - [Prioritization of patient care needs (mention if available)] Plan: - [Care plan adjustments or interventions planned for the shift, including medication administration, wound care, mobility assistance, patient education, etc. (mention if available)] - [Scheduled procedures or tests for the day (mention if available)] - [Collaboration with other healthcare team members (mention planned discussions or interventions involving physicians, physical therapists, social workers, etc.) (mention if available)] Interventions: - [Specific nursing interventions performed or initiated during the shift, including administration of medications, treatments, patient education provided, coordination of care, etc. (mention if available)] - [Response to interventions (mention if available)] Evaluation: - [Evaluation of patient’s response to interventions and progress towards care goals (mention if available)] - [Any changes in patient status or findings (mention if available)] Plan for Continuing Care: - [Next steps in patient’s care plan, including any planned adjustments to interventions, additional tests or procedures, follow-up needs, etc. (mention if available)] [Additional Notes:(mention only if available)] - [Any patient or family education provided, including discharge planning or instructions for home care (mention if available)] - [Communication with patient and family about care decisions, concerns, and preferences (mention if available)] - [Any safety concerns or incidents reported (mention if available)]

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