Complete Guide to Nursing Notes with Examples

Navigating Nurses’ Notes: A Useful Guide with Examples

Nursing documentation is essential in healthcare service, whether you are a new nurse graduate, a nursing student, or have years of experience.

Knowing how to chart all the required documentation is vital for your professional integrity and the safety of yourself, your patients, and your colleagues. Furthermore, in the nursing profession, accurate documentation is a legal requirement.

Nurses’ notes are among the most essential documents for the healthcare team. Keep reading to know why nursing notes are so important, why it is crucial to take good notes, how to do it, what information is needed, how to find the right balance, and more.

What Is a Narrative Nursing Note?

A narrative nursing note is one type of nursing documentation that gives important information about the patient. It usually encloses one or two paragraphs that include the patient's care, their response to the treatment, and the interventions and education the nurse provides for the patient.

Nursing notes let other multidisciplinary team members know what interventions nurses performed on the patient. These notes may include subjective data (the patient telling you how they feel) and objective data (the nurse assessing the situation and the treatment for the patient).

Taking nursing notes can prove to be quite challenging, and it is a skill you must practice as a nurse.Most nursing schools spend significant time stressing the importance of charting. Knowing what to write and when to do it, including subjective or objective data, and understanding the balance between being too detailed and too vague are the keys to writing good nursing notes. So, let’s start with the essentials and analyze some examples of practical nursing notes.

Characteristics of Effective Nursing Notes with Examples

Effective nursing notes have the following characteristics:

Medical Terminology: Use the correct vocabulary and clinical terms when writing nurses’ notes. When referring to what a patient said, you can use quotation marks. For example, the patient says she “used her inhaler” before coming to the hospital.
Caution: Be observant and gather enough information to make informed clinical decisions. For example, if somebody else wrote that a patient was oriented to name, place, time, and situation—but you have doubts—you should double-check during your assessment.
Detail: When you write nurses’ notes, you must describe what you did and said to the patient. Most nurses prefer to make notes as soon as they finish with a patient to avoid forgetting anything potentially important. Of course, you need to find a balance so the notes are not too long but cover all relevant details. Remember that notes will come in handy to asses that same patient later.
Readability: Most healthcare facilities use digital charting systems nowadays, but if you need to handwrite your notes, they should be clear and readable. Write well-structured sentences with the active voice instead of the passive voice. For example, “I educated the patient on the correct use of her medication” instead of “patient was educated on medication.” As you can see from the nurse's notes examples, effective communication is vital when writing them.

Tips for Writing Effective Nursing Notes

These tips can help you significantly improve your nursing notes:

Be specific and stay on topic.
Use short sentences.
If possible, use bullet points.
Add small details that you consider essential.
If the patient has more than one condition, it is crucial to prioritize the more significant condition in the notes.
Sign the nursing note.

Remember, when you are writing nurse notes, always be clear, avoid grammar or spelling mistakes, and ensure other team members will be able to understand the notes. This includes utilizing the correct symbols; omissions must be crossed out with a single line. Never delete or use whiteout to correct a nursing note.

Remember always to write your nursing notes as soon as you are able.

What Is the Difference between Charting and Nursing Notes?

There are many documents nurses need to fill out or create when taking care of their patients. One of them is charting, which includes institution-specific requirements. Charting differs from nursing notes because all healthcare professionals use charting for the patient and documenting the medications, physical examinations, interventions, etc. On the other hand, nursing notes narrate a nursing care encounter with a patient. Notes might vary in length; however, good nursing note examples always describe the nurses’ decision-making process with that specific patient.

Electronic Charting Nursing Notes

Healthcare IT systems for facility documentation record the treatments administered to patients and their data. They can help improve the nursing process and the delivery of care. Most nursing charting and nursing note examples in electronic format are easier to read and understand and, at the same time, improve communication of patients’ data and records, given that all healthcare providers use the same information.

Nurses must know how to use the charting system for each facility in which they work. Nurses’ notes differ from other nursing documents and are valuable for clinical practice.

Standard Templates for Nursing Notes

There are many templates for nursing notes. Here, we will describe three of them based on their mnemonics:

DAR

This mnemonic stands for Data, Action, and Response, and it is a template that can be as short or long as a nurse needs it to be.

DAR Example

Data: Data includes the patients’ subjective description of the condition and the nurses’ objective observations, all of which will lead to taking specific actions.

Action: The nurse’s actions include what the nurse did for the patient, for example, administering medications, educating the patient, etc.

Response: The nurse should always specify the treatment outcome in the response, in other words, if the action the nurse took solved the problem.

SOAPIE

This is another common mnemonic used in nursing, especially for nursing notes. It stands for Subjective, Objective, Assessment, Plan, Implementation, and Evaluation. It is more structured than DAR and helps healthcare professionals communicate both thoroughly and concisely. This form accurately depicts the plan of care at all steps. Some nurses also use the acronyms SOAP (including the first four points of consideration) or SOAPIER (including Revision).

SOAPIE Example

Subjective: Nurses can write down some of the patients’ words in quotation marks, describing in their own words how they feel.

Objective: This includes the physical examination findings, vital signs, lab results, and other measurable information.

Assessment: The nurse describes what is happening to the patient by interpreting the subjective and objective data.

Plan: The nurse outlines the steps to improve the patient’s condition. This plan includes therapy, medication, patient education, or referral (in case the nurse needs another healthcare team member to assess the patient).

Implementation: Here, the nurse records the actions and procedures implemented to improve the patient’s condition.

Evaluation: Evaluation is similar to response in DAR. It specifies the outcome of the treatment given and whether the result was successful.

ISBAR

The World Health Organization endorses ISBAR, a system adapted from the United States Navy (SBAR) to ensure proper communication among all parties. When all healthcare professionals use the same language, the specific template doesn’t affect the outcome as long as all parties are clear on important details and are appropriately trained in the method. ISBAR stands for Introduction, Situation, Background, Assessment, and Recommendation.

ISBAR Example

Introduction: You put your name, role, and what you communicate with the patient.

Situation: You state what goes on while you are with the patient in clear and brief language.

Background: What are the issues that led to this situation? You briefly describe what led to the patient having that specific condition.

Assessment: Your thoughts on the problem. You share your opinion on what the condition is.

Recommendation: What do you think should be done?

This last method is widely used for referrals, so it needs to be brief but detailed enough so the person receiving it can quickly understand what follow-up actions are required.

Overall, whatever the format, a nursing note must include the following:

The nurse’s name and role.
The patient’s name.
The date and time of the nursing note.
A description of the nursing process.

A Sample of Nurse’s Note

The following is an example of a nurse’s note:

Renal Vasculitis Nursing Note (Fictional Example)

Date: March 26th, 2023

Patient Name and Age: Kasey Example, 35

Chief complaint: The patient reported edema in her lower limbs, bruising in her upper limbs, difficulty breathing, persistent headaches, and decreased visual acuity since the beginning of March.

Diagnosis: Renal Vasculitis

History: The patient reports having had similar symptoms in the past month and several episodes of edema. She underwent hemodialysis for kidney problems on March 3rd.
The patient has not been taking her prescribed medication.

Physical exam: Vital signs are as follows:

Pulse = 110 beats per minute
Respiration = 24 breaths per minute
Temperature = 98.2 degrees Fahrenheit (F)
Blood Pressure = 130/90

The patient is lucid; her nutritional status is thin, and she presents mild yellow coloration of her skin, with bruises on the upper limbs.

After the physician’s assessment, she started a new hemodialysis treatment, and I administered Furosemide intravenously at 2100. After this treatment, she presented a reduction in the edema of the lower limbs and reported the disappearance of her headache. Furthermore, her urinary output increased; the 8-hour total was 1800 ml.

The patient asked many questions regarding her diet. I educated the patient about her diet and the importance of getting hemodialysis in time. The patient stayed overnight for observation.

Nurse in charge: Miriam Example, RN

Example of Good Progress Nursing Notes

Nursing notes can be progressive for the same patient, for example, with inpatients in hospitals, long-term care facilities, or any healthcare setting where the patient stays for a couple of days or more.

Other Considerations for Writing Nursing Notes

Remember that with per diem jobs, you may not be at a facility longer than one shift. Since you may not be available to explain what you observed or what needs to be done with a patient, having high-quality nursing notes will be essential for the healthcare professionals who care for the patient after you.

Remember always to write your nursing notes as soon as you can. Memory can fail you if you take too long. Charting as you go will help ensure accuracy and effective nursing notes.
As you can see, the format when taking notes will vary from facility to facility, so if you are ever in doubt during a per diem shift, feel free to ask colleagues. It’s better to ask questions than to omit information the facility requires.
Try to use precise language in your nurse notes, and if you have to handwrite them, use a blue or black pen. Never use a pencil for charting nursing notes.
If you are new to the process of taking nursing notes, you can take short notes for yourself while assessing the patient; that way, you will have most of the information later.
Remember, nursing notes are accessible to the medical team and are valuable so everybody can access accurate, concise, and specific information regarding the patient.

Perhaps one of the most critical questions is, “If I received this note, would I be able to continue with the care the patient needs?” If the answer is yes, you did it well and are ready to go.

Continue improving your nursing skills by reviewing how to perform a head-to-toe nursing assessment.

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