Nursing Progress Note (Assessment–Intervention–Evaluation)

Nursing Progress Note — Assessment–Intervention–Evaluation (AIE)

(Use objective, observable descriptions with measurable data. Emphasize clinical reasoning and closed-loop reassessment. Avoid duplicating flowsheet or MAR data—capture only what impacts continuity and decision-making. Use facility-approved abbreviations. Include event times for PRNs, acute changes, provider notifications, and safety events.)

Date/Time: [date and time authored]

Interval Covered: [start time]–[end time]

Author: [name, credentials, role]

Location: [unit/room if not auto-populated]

Assessment

[Interval stability/trajectory and primary active problems] (1–3 sentences summarizing overall stability vs. change, main active issues, and key watch-outs.)

• [Chief nursing concerns for this interval] (Brief bullets; highest acuity first.)

(For each clinically relevant problem, document subjective reports, objective findings, and applicable risk status. Organize by clinical priority. Include safety checks, device/line status, or precautions only if changed or newly implemented.)

[Problem/Focus Area]

• Subjective: [Pertinent patient/caregiver reports] (Include direct quotes when useful.)
• Objective: [Focused assessment findings] (Include only clinically meaningful findings; do not restate full head-to-toe.)
• Risk status/precautions: [falls / skin breakdown / aspiration / VTE / delirium / isolation] (Only if applicable or changed.)
• Devices/lines/safety measures: [Status or changes affecting care] (Only if changed or required by policy.)

(Repeat for additional problems as needed. If a required assessment was not performed, document "Not assessed" with reason and follow-up plan.)

Interventions

• Nursing actions: [PRN medications / titrations / holds / refusals / non-pharmacologic care / procedures / protocol implementation] (Include medication details, times, and rationale for clinically significant actions.)
• Communications & coordination (SBAR): [Who contacted] at [time] regarding [issue] — [what reported] — [response/orders received] — [next steps]
• Education: [topic] — [method], [learner], [barriers if any], [evidence of understanding: teach-back / return demo]

Evaluation

(Tie reassessment findings to each original problem and intervention. Document measurable response and goal status.)

[Problem/Focus Area]

• Response to interventions: [Objective changes with before/after metrics when available]
• Goal status: [met / partially met / not met] (If not met, state why and how plan was adjusted.)

(Repeat for additional problems as needed.)

• Pending/unresolved items: [Results awaited, response-pending interventions, issues requiring follow-up] (Include expected timing and responsibility.)

Plan for Next Interval

• Monitoring priorities: [What to monitor, frequency, escalation thresholds]
• Planned actions: [Scheduled interventions, reassessments, time-bound tasks]
• Coordination needs: [Pending consults, therapies, tests, discharge barriers]
• Must-mention items: [Critical changes, new orders, pending labs, family concerns, code status changes] (Highest-risk items first.)