01 / ADAPTABLE OUTLINE
What to document
Interval history & nursing update
Reason for rounds, new symptoms, falls, intake, weight trend, bowel and bladder changes, sleep, behavior, and information source. Note limits to the resident's history.
Baseline, function & examination
Recorded vitals, cognition compared with baseline, mobility and transfers, ADLs, pain, hydration, cardiopulmonary findings, skin concerns, and a symptom-directed exam.
Problem-oriented assessment & medication review
Separate stable chronic problems from new changes. Reconcile the MAR, recent orders, PRN use, efficacy, adverse effects, renal considerations, and potential contributors to falls or confusion.
Facility plan & communication
Specific orders, nursing monitoring and notification thresholds, therapy or pharmacy review, goals of care, verified code-status orders, family communication, and reassessment.
02 / WORKED EXAMPLE
Routine rounds after a recent fall
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
Interval history
A 84-year-old resident is seen during nursing home rounds one week after a fall. Nursing reports no further falls, head-injury symptoms, new pain, or change in transfers. Appetite and bowel pattern are at baseline. The resident denies pain but has limited recall; history is supplemented by nursing and the facility record.
Focused examination
BP 126/72 mmHg, pulse 74, respiratory rate 16, temperature 36.7°C. The resident is awake and conversant, with cognition consistent with documented baseline. No focal tenderness is identified on the examined limbs. Transfers are observed with usual staff assistance. Lungs are clear and no new peripheral edema is present.
Assessment & plan
1. Recent fall: no new injury findings today. Continue staff-assisted transfers and the individualized mobility plan. Therapy will review transfer technique and the walking aid. 2. Chronic cognitive impairment: no observed or reported acute change today. Continue familiar routines and cueing; reassess promptly for an acute change rather than assuming progression of dementia. 3. Medication review: MAR, recent changes, and PRN use reviewed; no medication changes ordered at this visit. Pharmacy review requested for potentially sedating agents.
Monitoring & coordination
Plan reviewed with the nurse. Notify the clinician promptly for another fall, new pain, reduced intake, new weakness, or altered mental status; use the emergency escalation process for acute severe symptoms. Advance-care documentation was reviewed in the chart; no change was made. Follow up in one week to review mobility and pharmacy recommendations, sooner for a change in condition.
03 / SETTING-SPECIFIC CARE PLAN
Treatment, monitoring & coordination
Adapt the plan to the patient, care setting, and goals. These prompts do not create orders or imply that care was performed.
Medication and fall-risk review
Document the actual MAR reconciliation and any prescription changes, including dose, route, frequency, indication, and monitoring. Review effectiveness and adverse effects of PRN medicines; do not stop a contributing medicine without a safe individualized plan.
Function, skin and nutrition
Include observed function and the facility's monitoring plan. Tailor therapy, nutrition, continence, and skin interventions to the resident's current needs and preferences.
Changes in condition
Specify who should be contacted, when reassessment will occur, and how urgent deterioration is handled. Significant changes warrant reassessment and an updated care plan, not simply a copied stable rounding note.
A common documentation question
Can this be used for both routine and acute nursing home rounds?
Yes, as a documentation framework. An acute change needs a focused assessment, an explicit differential when relevant, timely escalation, and a new plan rather than a routine stable-visit narrative.