Learn by Example

Progress Note Templates & Real Examples

See what audit-ready progress notes actually look like. Download templates, learn from real examples, and transform your documentation in minutes.

Why Real Examples Transform Documentation

See What Good Looks Like

Training says "be specific" -but what does specific REALLY look like? Examples show it.

Use as Starting Point

Don't write from scratch. Adapt templates to your residents. Templates save time and ensure consistency.

Build Confidence

Staff feel more confident writing notes when they can see examples of what auditors want to see.

5 Essential Progress Note Templates

1. Daily Living Activities (ADL) Template

For documenting routine care like showering, dressing, meals -the most frequent notes you write

Template:

WHO: [Resident name] WHEN: [Date, time] WHAT: Assisted with [specific activity]. Resident chose [preference]. HOW DID THEY RESPOND: [Mood, engagement, any concerns] CARE PLAN: [References goal, e.g., "Maintains independence in ADLs"] ESCALATION: [None/Noted]

Real Example:

WHO: Margaret WHEN: June 12, 8:30 AM WHAT: Assisted with morning shower. Margaret chose lavender soap and requested shower at 8 AM (her preference). HOW: Engaged well, smiled, asked about her granddaughter's visit. No pain reported. CARE PLAN: Morning routine per care plan. Supports goal of maintaining dignity and independence. ESCALATION: None. Continue current care plan.

2. Health Change / Concern Template

For documenting any change in health status -one of the most important notes you'll write

Template:

WHO: [Resident name] WHEN: [Date, time] OBSERVATION: [Specific observation of change] - Change from baseline: [how is this different?] TIMELINE: [When did this start? Getting worse/better?] ACTION TAKEN: [What did you do? Who did you tell?] ESCALATION: [Who was notified? When? What was their response?] NEXT STEPS: [What's the plan?]

Real Example:

WHO: James WHEN: June 12, 10:00 AM OBSERVATION: James breathing faster than usual (usually 16-18/min, now 22/min). Appears more fatigued. TIMELINE: Started this morning. Not his usual self. ACTION TAKEN: Checked vital signs. Offered to rest. Asked if in pain -he said no. ESCALATION: Reported to RN Carol at 10:15 AM. RN completed assessment. Suspected respiratory infection. GP called. NEXT STEPS: Awaiting GP visit. Monitoring vital signs. Keep resident comfortable.

3. Behavioral or Mood Change Template

For documenting changes in behavior, mood, or engagement -critical for early intervention

Template:

WHO: [Resident name] WHEN: [Date, time] OBSERVATION: [Specific behavior observed] - Not typical for [resident name] BASELINE: [What's usually normal for this person?] POSSIBLE TRIGGERS: [What might be causing this?] RESPONSE: [How staff responded] - What worked? ESCALATION: [Reported to: ___ at ___ time] PLAN: [What's next?]

Real Example:

WHO: Patricia WHEN: June 12, 2:00 PM OBSERVATION: Patricia unusually quiet, withdrawn. Declined to join her usual group activity. BASELINE: Patricia is usually sociable, enjoys group time. Initiates conversations. TRIGGERS: No obvious trigger. May be tired? Mood low? RESPONSE: Checked in with her privately. Asked how she's feeling. She shared that her son hasn't visited in a while -missing family. Listened, validated feelings. Offered to help her write a letter. ESCALATION: Informed RN. No medical concerns noted. May benefit from extra family contact/support. PLAN: Continue monitoring. Encourage activities. Family to visit Friday.

4. Medication / Treatment Response Template

For documenting how residents are responding to medications or treatments

Template:

WHO: [Resident name] WHEN: [Date, time] MEDICATION/TREATMENT: [What was given/done] TIME GIVEN: [Exact time] RESPONSE: [How did resident respond?] SIDE EFFECTS: [Any observed side effects?] EFFECTIVENESS: [Is the medication/treatment working?] NOTES: [Any concerns? Any changes needed?] ESCALATION: [If concerns, who was informed?]

Real Example:

WHO: William WHEN: June 12, 4:00 PM MEDICATION: Pain relief medication administered (per GP orders) TIME: 4:00 PM RESPONSE: William took medication without complaint. Settled into chair afterward. EFFECTIVENESS: 30 minutes later, William reported pain reduced from 7/10 to 4/10. Seems more comfortable. SIDE EFFECTS: None observed. No drowsiness or nausea reported. NOTES: Pain relief working well. Timing before dinner activities appears optimal. ESCALATION: None. Continue as prescribed.

5. Family Communication Template

For documenting important conversations with family -shows partnership in care

Template:

WHO: [Resident name] FAMILY CONTACT: [Who you spoke to] WHEN: [Date, time] PURPOSE: [Why did you contact? What was discussed?] KEY POINTS: [What was shared/discussed?] RESPONSE: [How did family member respond?] DECISIONS: [Any decisions made together?] NEXT STEPS: [What will happen next? When?]

Real Example:

WHO: Margaret FAMILY CONTACT: Daughter Sarah WHEN: June 12, 2:30 PM (phone call) PURPOSE: Update Sarah on Margaret's recent falls (3 in past 2 weeks) KEY POINTS: Explained assessment findings. Discussed physical therapy referral. Answered questions about safety. RESPONSE: Sarah was concerned but appreciative of update. Asked good questions. Wants to be involved in next steps. DECISIONS: Sarah will visit Saturday to see mum and meet with therapy team. Together we'll discuss home modifications. NEXT STEPS: PT assessment scheduled for Friday. Will update Sarah after. Plan family meeting for Saturday.

Download All 5 Templates

Get printable progress note templates for your facility. Print and post in break rooms, at bedside, or share digitally with your team.

How to Use These Templates Effectively

1. Customize for Your Residents

Don't use templates as fill-in-the-blank. Use them as structure. Adapt to each resident's individual needs, goals, and preferences.

2. Train All Staff

Show templates in team meetings. Discuss examples together. Let staff practice using templates. This builds consistency.

3. Post Templates Visibly

Print and post in break rooms, at bedside, on whiteboards. Make templates easy to reference without digging through files.

4. Use as Peer Learning

Share excellent notes written from templates. 'Look at how Sara documented this' -peer examples inspire and train.

5. Audit Against Templates

When auditing notes, check them against templates. Does each section include required elements? Use as checklist.

6. Evolve Templates

Templates aren't fixed. As you learn what works, update templates. Make them better over time.

Make Progress Note Writing Easy

AccuNote brings templates and drafting support into one workflow. Staff can review each draft for clarity and relevant details before recording it through their organisation's process.