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Nursing Notes:
How to write
them (with
Examples)
Written by
Alex Lukey, MSN, RN

Although nursing documentation may at

times seem overwhelming, it is a key part
of nursing practice. Colloquially known
as “charting,” nursing documentation
provides a record of nursing care
provided to a patient, family, or
community. Charting and, more
speciFcally, nursing notes, allow nurses
to demonstrate that the care they
provided was ethical, safe, and informed
by relevant nursing knowledge.

In this article:
Nursing Notes vs. Charting
How Are Nursing Notes Used?
How to Write Good Nursing Notes
(What’s included)
Nursing Note Examples
SOAPIE Example
DAR Example
General Advice on Writing Nursing
Notes
References

Nursing Notes vs.

Charting
Charting is a nursing process that
includes all the documentation required
from nurses. This might include legal,
professional, and institution-speciFc
requirements. Some examples of
charting include documenting
medications administered, vital signs,
physical assessments, and interventions
provided. Nursing notes are a narrative
written summary of a given nursing care
encounter. This might include a
description of a nursing visit, a speciFc
care event, or a summary of care. A
nurse’s note is a form of charting that
describes the nurse’s decision-making
process regarding the nursing care
provided.

Nursing notes are an important part of

high-quality nursing documentation
because they provide an opportunity for
nurses to demonstrate their nursing
knowledge and communicate the nursing
process to other team members of the
patient’s interprofessional care team.

···

How Are Nursing

Notes Used?
A clear and comprehensive nursing note
serves several purposes in nursing
practice, both in patient care and to
provide legal protection to the nurse
writing the note. Reasons to write high-
quality nursing notes include:

Contributing to continuity of care

for patients. Continuous care
requires that the care provided to
the patient is well-organized and
that there is cooperative
communication between nurses
and other interdisciplinary team
members. Continuous care
contributes to patient-centered
and safe care. Nursing notes allow
all people on the care team to
understand the patterns of patient
care.1
Communicating care goals.
Nursing notes are one place
where the nurse can share the
plan of care with team members.
Nursing notes also allow others to
see what interventions have been
performed so far and what the
outcome of those interventions
were.
Demonstrating the nurse’s
knowledge as required by
professional regulators. Nursing
notes are useful for
demonstrating the knowledge,
skill, and judgment required by the
nurse’s professional regulators,
such as their college. In addition,
if there is ever a concern about a
nurse’s license, nursing notes can
be used as evidence of competent
and safe practice in line with
professional standards of
practice.
Contribute to quality
improvement. Quality
improvement projects across
nursing settings may include a
review of charts to understand the
care process. Nursing notes that
accurately and comprehensively
reYect care delivered allow for
more precise quality improvement
initiatives.
Contribute to nursing research.
Nursing research projects may
include a review of the chart.
Similar to quality improvement
initiatives, nursing notes that
accurately reYect the care
provided allow accurate research
data to be collected.
Legal protection. Nursing notes
are included in the patient/client’s
permanent medical record. In the
case of legal action related to care
that a nurse provided or was
involved in, nursing notes
demonstrating that ethical and
competent nursing care was
delivered provide legal protection
to the nurse.
Reimbursing insurance claims. In
some jurisdictions, insurance or
other healthcare payers may
directly reimburse nursing care.
The nursing note may describe the
rationale for reimbursable nursing
activities in this case.

···

These are just a few key reasons nurses

should spend time and effort writing
high-quality nursing notes.

How to Write Good

Nursing Notes
(What’s included)
Different work settings may have an
expected format or even templates for
nursing notes. However, all nursing notes
should include evidence of the nursing
process. There are different templates
for what should be included in a nursing
note. Institutional or hospital policies
may be in place on what should be
included in the nursing note. However, it
is the individual nurse’s responsibility and
a demonstration of nursing knowledge
and judgment to decide what information
is relevant or irrelevant for the nursing
note.

···

Nurses’ notes usually include subjective

(what the patient tells you) and objective
(assessment/analysis) data. However,
the nurse should be careful not to include
judgements or their own opinion in
nursing notes. It is important to include
subjective data. However, subjective data
should be written in quotation marks as
statements made by the patient rather
than objective facts.

Two common templates for nursing

notes use the mnemonics DAR and
SOAPIE. Rather than absolute rules that
describe how a nursing note should be
structured, these two mnemonics are to
be used as guidelines and to help the
nurse remember what information
should be included in their note.

SOAPIE: subjective (what the patient

tells you), objective (the nurse’s
assessment), analysis (interpretation of
data), plan (what the nurse plans to do),
implementation (what was done) and
evaluation (how did the intervention
work?)

···

DAR: Data (both subjective and

objective), action (what was done),
response (how did the patient respond?

There are other acceptable templates for

nursing notes. The nurse should check
with their institution if there is a preferred
or institution-speciFc policy regarding
what should be included in the nursing
note. Overall, what must be included in
the nursing note is the nurse’s own name,
the name of the patient/client, the date
and time of the note, and a
demonstration of the appropriate nursing
process. Nursing notes should also be
made in chronological order.

When writing a nursing note regarding a

consultation with another healthcare
provider, the nurse should include the
name and designation of the other
healthcare provider in addition to other
components of the nursing note.

···

Nursing Note
Examples
In the following section you will Fnd
nursing note examples for the SOAPIE as
well as for the DAR format.

SOAPIE Example
Patient: Jane Doe
Date: January 30, 2023

13:17: Patient reports pain to lower

abdomen, rates pain at 7/10. She states
that the pain has been increasing over
the past half hour after her return from
PACU. Mrs. Doe describes the pain as a
“dull ache.” (Subjective) Abdominal
dressing is dry and intact. Bowel sounds
are hypoactive X4. Most recent vital
signs BP 114/82, HR 88, respiration 18,
Sp02 94% on room air. (Objective)
Patient experiencing post-operative pain
related to recent hernia operation.
(Analysis) Writer will offer patient
education regarding PCA usage. (Plan)

···

13:26: Writer reminded the patient about

how to use the button on her PCA to
control her pain. Writer educated patient
on the importance of managing post-
surgical pain early to maintain comfort.
(Intervention)

13:57 Reassessed patient pain after PCA

education. Patient now describes that
her pain is “subsiding.” When rating her
pain on the pain scale, patient now
describes her pain as 2/10 which is
acceptable to her. (Evaluation)

This note includes all elements of the

SOAPIE note and also is written at the
time in which the activity was performed
so there is a clear sequence of events.

···

DAR Example
Patient: Jill Doe
Date: January 30, 2023

0927: On assessment patient described

increased shortness of breath related to
her chronic asthma. Patient stated that
she “uses her inhaler at home when I get
short of breath.” Patient respiration rate
22, Sa02 92% on room air, wheeze
audible on auscultation of lungs. (Data)
Writer administered 2 puffs (34 mcg) of
patient’s Ipratropium PRN inhaler.
(Action) Patient states that shortness of
breath now resolved. (Response)

General Advice on
Writing Nursing
Notes
Writing high-quality nursing notes is a
skill like any other nursing skill that takes
time and focused effort to improve. With
practice, nursing notes will become
second nature as one pillar of safe and
effective clinical practice. Here are a few
quick practice pointers to improve your
nursing notes.

···

If you are using paper charting,

ensure that the writing is legible.
Illegible charting does not
accomplish the goal of
communicating care to the team
and will not legally protect the
nurse.
Include both subjective and
objective data. Including both
subjective and objective data in
the nursing note creates a
comprehensive clinical picture.
Remember to document
signiGcant interactions with
family members, signiFcant
others, or substitute decision-
makers. This might include
interactions such as a family
member describing the patient’s
medical history when the patient
is unable to do so themselves.
Limit your use of abbreviations. If
you do use abbreviations, ensure
that they are allowed for your
institution
Document as soon as possible
after the care interaction. It is
preferable to document the care
interaction as soon as possible. If
the nurse waits to document, they
may forget important details.
If an error is made in
documentation, do not delete,
white-out, or attempt to erase the
error. Instead, document that the
Frst entry was made in error by
drawing a line through and
initialing for paper charting or
following the correct procedure
for the electronic medical record.
For paper charting, use only black
or blue ink, which is accepted in
legal proceedings and is the
easiest to read.
Read other documentation on the
patient! This could include other
members of the interprofessional
team or nurses’ notes on the
patient. These notes may include
helpful information that may
inform your care of the patient.
However, a word of caution is that
the nurse should never rely on
another’s assessment. Always
double check the details of the
patient’s history and make your
own assessment.

To ensure high-quality nursing notes, the

nurse might ask themselves if their note
adequately answers the following
question: “If another nurse were to take
over this assignment, without a verbal
handover, is there enough information
here that they could provide safe and
continuous care for this patient?”2 If the
answer is no, the nurse might consider
that more detail ought to be provided.

References
1. College of Nurses of Ontario.
Documentation, Revised 2008.
Published online 2008. Accessed
January 28, 2023.
https://www.cno.org/globalassets
/docs/prac/41001_documentatio
n.pdf
2. College of Registered Nurses of
Manitoba. Documentation
Guidelines for Registered Nurses.
Accessed January 28, 2023.
https://crnm.mb.ca/wp-
content/uploads/2022/01/Docum
entation-Guidelines-for.pdf
 ···

Published on February 4, 2023

Photo of author

Alex Lukey, MSN, RN

Alex Lukey is a registered nurse and
researcher. Alex earned her bachelor's
and master's degrees in nursing from
the University of British Columbia
Okanagan. She is now working on a
Ph.D. in Public Health as a Killam
Scholar at the University of British
Columbia. Alex's research has spanned
health policy, patient education, and
oncology. She is currently working on
ovarian cancer prevention using
machine learning. Her clinical practice
experience includes cardiology, cardiac
surgery, and pediatric homecare. Alex is
passionate about science
communication and education.

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