Progress Note

Patient: Jane Doe Medical Record Number: 1234567 Date: 01 November 2024 Progress Notes JD 09:00: Patient reports feeling slightly better this morning, pain level is now a 3/10. Administered morning medications as prescribed. Assisted patient with morning hygiene. Vitals stable: BP 120/80, HR 78, Temp 98.6F, SpO2 98% on room air. Encouraged patient to ambulate in the hallway for 10 minutes. Patient tolerated activity well. No new concerns reported. JD 12:00: Patient ate 75% of lunch. Pain level remains at 3/10. Wound dressing changed, wound appears clean and dry. Patient verbalized understanding of wound care instructions. Provided education on signs and symptoms of infection. Patient denies any new complaints. JD 16:00: Patient resting in bed. Pain level remains at 3/10. Reviewed discharge instructions with patient and family. Patient and family verbalized understanding of instructions. Scheduled follow-up appointment with primary care physician. Patient appears to be in good spirits. Name of Staff Member: Jane Doe, RN