Complete Guide to Nursing Notes with Examples

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23 hours ago
3 min read

If you’re a nurse, chances are you’ve either stared at a blank screen, unsure how to start your note, or rushed through documentation only to wonder if you covered everything.

In this blog, we’ll walk through the basics of writing strong nursing notes, including popular formats, and provide real-world examples to help you feel more confident and less stressed.

Need help writing faster, professional notes? Tools like NurseMagic™ let you speak or type your scenario and choose a format, and your note is generated in seconds. Professional, HIPAA-compliant, and built for nurses.

Why Nursing Notes Matter

Nursing documentation helps ensure continuity of care, improves patient safety, and protects you in case of audits or legal action. Done well, notes save time later. Done poorly, they lead to confusion, charting rework, or worse, noncompliance. Studies have found that up to 86% of claim denials could be prevented with better documentation.

So let’s break down how to get it right, without burning yourself out.

Choose the Right Format for the Situation

There are several standard formats used in nursing documentation. Here are the most common ones:

1. SOAP – Subjective, Objective, Assessment, Plan

Used most often for progress notes and clinical documentation.

Example:

S: Patient reports “sharp pain” in lower abdomen rated 7/10.

O: BP 130/85, Temp 99.3°F, guarding behavior noted.

A: Suspected early appendicitis.

P: Alerted provider; abdominal CT ordered. Will monitor vitals Q2H.

2. DAR – Data, Action, Response

Ideal for tracking patient issues during a shift.

Example:

D: Pt c/o nausea after breakfast. Emesis x1 noted, non-bilious.

A: Administered Zofran 4 mg IV per order.

R: Nausea resolved within 20 minutes. No further emesis noted.

3. Narrative Notes

Free-form and chronological. Great when events don’t fit a box.

Example:

Pt returned from PT at 10:45 am. Reported dizziness when standing. Assisted back to bed. Vitals stable. Called provider. Will reassess in 30 mins.

Tips to Level Up Your Nursing Notes

Even if you have the right format, your note won’t be useful unless it’s complete, accurate, and objective. Here’s how to get there:

✅ Be Timely

Chart in real time if possible. Delayed charting increases risk of errors or missing key info.

✅ Stick to the Facts

Avoid subjective language like “seemed upset” unless it’s backed up by behavior (e.g., “pt tearful, avoiding eye contact”).

✅ Use Approved Abbreviations

Stick with facility-approved terms. “SOB” might be fine to you, but it could confuse someone reading the chart.

✅ Cover All the Basics

Include date/time, your full name and title, patient identifiers, and avoid blank spaces or lines.

When in Doubt, Document It

If a patient refuses meds, calls you over with a concern, or has an unexpected reaction—even if it seems minor—it should go in your note. Here are some examples to guide you.

Refusal of Treatment

Narrative Note: Pt declined scheduled insulin dose at 1700, stating “I don’t feel like I need it.” Educated pt on risks of missed dose. Pt verbalized understanding. Endocrine consult notified.

Incident or Change in Condition

SOAP Note:

S: CNA reports pt “wasn’t acting right” during transfer.

O: Pt confused, unable to state name/date. BP 180/96. Pupils unequal.

A: Possible stroke.

P: Code stroke initiated. Pt transported to ER. Family notified.

Admission Note (using SOAPIE format)

S: Pt c/o chest tightness since early morning. Denies nausea.

O: HR 98, BP 145/92, O2 sat 96% on RA. ECG pending.

A: Chest pain—non-specific etiology.

P: Monitor vitals Q1H, await ECG, initiate telemetry.

I: 4L O2 via NC applied.

E: Pt resting comfortably. Will continue monitoring.

How to Make Documentation Easier (and Faster)

If documentation feels like it’s taking over your entire shift, you’re not alone. Nurses spend, on average, about 40% of their shift performing documentation. That’s hours every day.

Tools like smart templates, voice-to-text apps, and AI-powered documentation platforms (like NurseMagic™) can help reduce the time you spend typing without compromising quality. You still use your clinical judgment, but now your notes are clear, complete, and professionally written in seconds.

Final Thoughts

You don’t need to write a novel. You just need to write clearly, professionally, and consistently. Think of nursing notes like passing the baton: make sure the next nurse, provider, or auditor has everything they need to understand what happened.

Whether you're just getting started or brushing up after years in the field, solid documentation is one of the most powerful tools in your practice.

Now go write that note and get out on time.