Situation

[PATIENT NAME], admitted on [ADMISSION DATE] with a diagnosis of [DIAGNOSIS]. Currently, experiencing [OBSERVATION, CHANGES IN CONDITION OR BEHAVIOR]

Background

[PATIENT NAME] has a history of [MEDICAL HISTORY], including [RELEVANT MEDICAL CONDITIONS OR SURGERIES]. Previous treatment includes [PREVIOUS TREATMENT]. [PATIENT NAME]’s condition has [IMPROVED/WORSENED/STABILIZED] since the last shift.

Assessment

Vital signs as follows: HR: [HEART RATE], RR: [RESPIRATORY RATE], BP: [BLOOD PRESSURE], Temp: [TEMPERATURE], O2 Sat: [OXYGEN SATURATION]. Pain scale: [PAIN LEVEL]. Additionally, [ANY ADDITIONAL ASSESSMENT FINDINGS].

Recommendation

I would like to propose my professional recommendations for your care or treatment. It's essential to the success of your treatment, that any additional notes or concerns that may arise should be appropriately and timely addressed.