What are nursing notes? 

Nursing notes are written records detailing the care provided to a client, including observations, treatment plans, and interventions. They are essential for continuity of care and are a legal document. 

How to write a nursing note? 

Good nursing notes provide a detailed legal record of a client’s status, treatment, responses, and outcomes.

All nursing notes must be: 

• Factually correct
• Accurate and detailed
• Complete
• Current with exact time information
• Organized
• Professional

Tips for writing nursing notes: 

• Be sure to document the correct client, and under your own name and login.
• Document as soon as possible. Don’t wait until the end of the shift.
• Report and document missed or late entries immediately.
• Document the issue, what you did about it, and the client’s response.
• Document only what you see, hear, touch, smell, and do—avoid opinions. 
• Document often enough and with enough detail to tell the entire story.
• Document all communications—include names, titles, time, statements, and actions taken.

Free-form notes: nursing narrative notes

Writing nursing notes in a narrative format means telling the client’s story chronologically. The note will provide the information in free, written-out sentences.

An advantage is that notes in this format provide context and a fuller picture of the client’s situation, but they can be time-consuming to read and write.

Nursing note template: SOAP nursing notes

“SOAP” is short for “Subjective, Objective, Assessment, and Plan”. 

• Subjective: chief complaint and symptoms
• Objective: vital signs and other measurable data
• Assessment: clinical judgment of client’s progress
• Plan: treatments/intervention plans

Giving nursing notes this structure creates easier reading to scan quickly and reduces the possibility of errors and oversights by providing a standardized, focused documentation.

SOAPIE nursing note example  

The SOAP-format is often expanded to “SOAPIE”: Subjective, Objective, Assessment, Plan, Intervention and Evaluation. 

An example for this format would be: 

• Subjective: Client states: ‘I feel short of breath’
• Objective: Vital signs showed: BP 110/75; HR 100; RR 22; SpO2 89%
• Assessment: Client displays fatigue and is pale, states “tiredness”.
• Plan: This RN contacted the charge RN, rapid response nurse, and primary care physician.
• Intervention: Oxygen 2 L placed on the client via nasal cannula.
• Evaluation: SpO₂ increased to 95%, respiratory rate slowed to 18. The client was transferred from the med-surg unit to the ICU due to unstable condition per healthcare provider order. Report given to ICU nurse; family notified of transfer.

Nursing note template  (SOAPIE)

• Subjective: What did the client report?
• Objective: Vital signs/lab values 
• Assessment: What were your findings? 
• Plan: Who did you contact? 
• Intervention: Action/intervention(s) the nurse performed 
• Evaluation: What happened after the interventions?

Good nursing note example: dos and don’ts

Following are examples of nursing note excerpts that show the dos and don’ts of how to follow the requirements of a good nursing note: 

Make sure the nursing note is factual 

Don’t: Client seems like they are in pain.

Do: Client grimaced and moaned when their right leg was touched. 

Interpretations and assumptions are not facts. 

Make sure the nursing note is accurate 

Don’t: There was a large amount of drainage.

Do: 0910-Serosanguineous drainage of 150 mL.

“Large amount” as a quantifier leaves the information open to the reader’s interpretation. Stick to the facts and give them in the most detailed way possible. 

Make sure the nursing note is complete 

Don’t: Client was taught how to check their blood sugar.

Do: Client correctly demonstrates how to check their blood glucose.

Include how the teaching was done and the proof that it was successful. 

Make sure the nursing note is current 

Don’t: Client had an elevated temperature after breakfast.

Do: 0900-client’s temperature is 39.1°C (102.4°F)

This example shows again that it is important to be specific, precise, and to give all the available information. 

Make sure the nursing note is organized 

Don’t: Client had altered mental status, stomach pain, and could not recall their name.

Do: Client disoriented to time; points to dull stomach pain around umbilicus at 5/10 pain level.

Group related information together. 

Make sure the nursing note is professional 

Don’t: Client uncooperative and would not take meds. 

Do: Client refused 0900 meds. 

It is inappropriate to label clients as difficult, uncooperative, or use a negative description – simply state the actions, what happened, quotes stated and everything that may have kept you from taking measures you were supposed to. Leave out any personal perspectives, reactions, or feelings.