Progress Notes — PivotChart

New Progress Note

Discipline / Note Type *

Visit Date *

Visit Time

Time In

Time Out

Visit Setting

Vital Signs

BP (mmHg)

HR (bpm)

RR (breaths/min)

Temp (°F)

O₂ Sat (%)

Weight (lbs)

Blood Glucose (mg/dL)

Height (in)

Edema

Pain Score (0–10)

Pain Location / Description

Clinical Assessment

Chief Complaint / Reason for Visit

Subjective — Patient / Family Report

Objective — Clinical Findings

Assessment — Clinical Impression

Plan — Interventions & Follow-up

Symptom Management

Dyspnea / Shortness of Breath

Nausea / Vomiting

Anxiety / Agitation

Constipation

Appetite / Oral Intake

Level of Consciousness

Functional Status

Ambulation

Transfers

ADLs (Bathing/Dressing)

Safety & Environment

Safety Concerns (check all that apply)

Medications

Medication Review / Changes

Family & Caregiver

Caregiver Present

Family / Caregiver Coping

Education Provided

Physician Communication

Physician Notified?

Physician Name / Contact

Physician Communication Details / Orders Received

Next Visit

Next Visit Date

Next Visit Type

Frequency

Clinician Signature

Clinician Name *

Credentials / Title

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