About Prompt
- Prompt Type – Dynamic
- Prompt Platform – ChatGPT
- Niche – Healthcare
- Language – English
- Category – Nursing
- Prompt Title – ChatGPT Prompts for Nurses Shift Reports and Patient Care Notes
Prompt Details
This prompt is designed for nurses to generate comprehensive and accurate shift reports and patient care notes using ChatGPT. It incorporates dynamic elements, allowing for personalization based on individual patient needs and specific shift details.
**Instructions:**
1. **Patient Information:** Provide the following information about the patient:
* **Patient Name:** (e.g., Jane Doe)
* **Medical Record Number (MRN):** (e.g., 1234567)
* **Date of Birth (DOB):** (e.g., 01/01/1980)
* **Gender:** (e.g., Female)
* **Admitting Diagnosis:** (e.g., Pneumonia)
* **Allergies:** (e.g., Penicillin)
* **Code Status:** (e.g., Full Code)
* **Isolation Precautions:** (e.g., Contact Precautions)
2. **Shift Details:** Specify the following details about your shift:
* **Shift Start Time:** (e.g., 0700)
* **Shift End Time:** (e.g., 1900)
* **Date of Shift:** (e.g., 2024-03-15)
* **Your Role:** (e.g., Registered Nurse)
3. **Current Patient Status:** Describe the patient’s current condition, including:
* **Vital Signs:** (e.g., T: 98.6°F, P: 80 bpm, R: 18 breaths/min, BP: 120/80 mmHg, SpO2: 98% on room air)
* **Pain Level:** (e.g., 3/10, sharp pain in lower abdomen)
* **Neurological Status:** (e.g., Alert and oriented x4)
* **Respiratory Status:** (e.g., Clear lung sounds bilaterally)
* **Cardiovascular Status:** (e.g., Regular heart rhythm, S1S2 present)
* **Gastrointestinal Status:** (e.g., Bowel sounds present x4 quadrants, soft abdomen)
* **Genitourinary Status:** (e.g., Voided 500 mL clear yellow urine)
* **Musculoskeletal Status:** (e.g., Full range of motion in all extremities)
* **Skin Integrity:** (e.g., Intact skin, no wounds or pressure ulcers noted)
* **IV Access:** (e.g., 20G IV in left forearm, patent and infusing NS at 125 mL/hr)
* **Other Relevant Observations:** (e.g., Patient ambulated to the bathroom with assistance x1, tolerated well)
4. **Interventions Performed During Shift:** List all interventions performed during your shift, including:
* **Medications Administered:** (e.g., Acetaminophen 650mg PO at 1000 for pain)
* **Treatments Provided:** (e.g., Nebulizer treatment with Albuterol 2.5mg at 0800)
* **Wound Care:** (e.g., Dressing change to abdominal surgical site, no signs of infection)
* **Patient Education:** (e.g., Educated patient on importance of deep breathing exercises)
* **Other Interventions:** (e.g., Assisted patient with bathing and dressing)
5. **Output Request:** Specify the desired output format. Choose one or both of the following:
* **Shift Report:** Generate a concise and structured end-of-shift report summarizing the patient’s status, interventions, and plan of care.
* **Patient Care Notes:** Generate detailed and comprehensive nursing notes documenting the patient’s care during the shift.
6. **Optional Instructions:**
* **Focus:** Specify a particular aspect to emphasize in the output (e.g., “Focus on pain management” or “Focus on respiratory status”).
* **Tone:** Specify the desired tone of the output (e.g., “Formal” or “Informal”).
* **Length:** Specify the desired length of the output (e.g., “Brief summary” or “Detailed report”).
**Example:**
“`
1. Patient Information: Patient Name: Jane Doe, MRN: 1234567, DOB: 01/01/1980, Gender: Female, Admitting Diagnosis: Pneumonia, Allergies: Penicillin, Code Status: Full Code, Isolation Precautions: None.
2. Shift Details: Shift Start Time: 0700, Shift End Time: 1900, Date of Shift: 2024-03-15, Your Role: Registered Nurse.
3. Current Patient Status: T: 98.6°F, P: 80 bpm, R: 18 breaths/min, BP: 120/80 mmHg, SpO2: 98% on room air. Pain level 2/10. Alert and oriented x4. Clear lung sounds bilaterally. Regular heart rhythm. Bowel sounds present. Voided 600 mL clear yellow urine. Full range of motion. Skin intact. 20G IV left forearm, infusing NS at 125 mL/hr. Ambulated with assistance, tolerated well.
4. Interventions Performed During Shift: Administered Acetaminophen 650mg PO at 1000 for pain. Nebulizer treatment with Albuterol 2.5mg at 0800. Educated patient on incentive spirometry. Assisted with bathing.
5. Output Request: Shift Report and Patient Care Notes
6. Optional Instructions: Focus on respiratory status. Formal tone.
“`
This dynamic prompt provides a flexible framework for generating high-quality shift reports and patient care notes, streamlining documentation and improving communication within the healthcare team. Remember to always review and edit the generated text to ensure accuracy and completeness before incorporating it into the patient’s medical record. This prompt is an aid and not a replacement for professional clinical judgement.