Free Nursing Home Skilled Note Template
Nursing Home Skilled Note
Date: [September 18, 2024]
Time: [10:00 AM]
Patient Name: [John Doe]
Patient ID: [123456]
Room Number: [301]
Nurse: [Your Name], RN
Subjective:
John Doe reports feeling “a bit more tired than usual” this morning. He mentioned experiencing slight discomfort in his lower back but states that the pain is manageable and does not radiate to other areas. John also expressed gratitude for the support he’s receiving and is optimistic about his therapy sessions.
Objective:
Vital Signs:
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Temperature: [98.6°F]
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Pulse: [72 bpm, regular]
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Respiration: [16 breaths per minute]
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Blood Pressure: [130/80 mmHg]
Physical Examination:
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General: Alert and oriented to person, place, and time.
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Skin: No new rashes or bruises; skin intact with no signs of breakdown.
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Cardiovascular: Heart sounds normal, no murmurs or irregularities detected.
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Respiratory: Lungs clear to auscultation bilaterally, no wheezes or crackles.
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Musculoskeletal: Mild tenderness in the lower back, no swelling or redness noted. Mobility slightly decreased compared to previous assessments.
Wound Care:
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Pressure ulcer on the sacrum: Stage II, clean and dry with minimal drainage. Dressing intact.
Assessment:
John appears to be in stable condition with manageable symptoms. The mild back pain may be related to his recent physical therapy activities. No signs of acute distress or complications noted at this time. The stage II pressure ulcer is being managed effectively with current wound care protocols.
Plan:
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Pain Management: Continue with prescribed pain medication as needed. Monitor pain levels and adjust as necessary.
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Physical Therapy: Reinforce proper body mechanics during therapy sessions to minimize strain on the lower back.
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Wound Care: Continue current wound care regimen. Reassess the pressure ulcer during the next shift.
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Follow-Up: Schedule a follow-up appointment with the physician to review back pain and overall progress. Update care plan as needed based on physician’s recommendations.
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Patient Education: Educate John on techniques to relieve back pain and the importance of regular repositioning to prevent pressure ulcers.
[Your Name]
Title: Registered Nurse
License Number: [12345678]
