Free Nursing Note

Prepared by: [YOUR NAME]
Date and Time: 2054-01-17, 08:00 AM
Patient: John Scott
Age: 65
Medical Record Number: 123456
Complaint: Pneumonia
Patient's Report:
Cough, fever, and difficulty breathing for three days.
Vital Signs:
Temperature: 101.2°F
Blood Pressure: 120/80 mmHg
Heart Rate: 95 bpm
Respiratory Rate: 22 breaths/min
Assessment:
Signs of pneumonia, the risk for breathing difficulties.
Interventions:
Gave antibiotics and a fever reducer.
Provided oxygen through the nasal cannula.
Encouraged deep breathing exercises.
Educated patient and family on infection control.
Response:
Fever reduced to 99.5°F.
Oxygen levels improved to 96%.
The patient feels more comfortable.
Plan:
Continue antibiotics, and monitor progress.
Check vital signs regularly.
Promote mobility.
Collaborate with respiratory therapy.
Physician notified. Ongoing monitoring and care are planned.
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Use our Nursing Note Template, which is available on Template.net, to improve your nursing documentation. To alter specifics like patient assessments, therapies, and responses, use our AI Editor Tool. This template aids nursing staff in keeping complete and accurate records, supporting effective patient care, and enabling smooth communication across healthcare teams.
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