Nursing Notes Template

Nursing Knowledge

Nursing Notes Template

Nursing notes are written records that document patient care and serve as a communication tool among healthcare professionals. Patient symptoms, treatment plans, medications are documented in nursing notes to ensure continuity and quality of care. Mastering them early on is vital since nursing notes are not only essential for patient safety but also can have legal implications.
Last updated: December 4, 2023

Table of contents

What are nursing notes? 

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

How to write nursing notes 

Good nursing notes provide a detailed legal record of a patient’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 patient, 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 patient’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 patient’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: complaints and symptoms
  • Objective: vital signs and other measurable data
  • Assessment: clinical judgment 
  • 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: Patient states: ‘I feel short of breath’
  • Objective: Vitals signs showed: BP 110/75; HR 100; RR 22; SpO2 89%
  • Assessment: Patient 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 patient via nasal cannula.
  • Evaluation: SpO2 increased to 95%, respiratory rate slowed to 18. The patient 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 patient 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: Patient seems like they are in pain.

Do: Patient grimaced and moaned when their 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: There was 150 mL of serosanguineous drainage.

“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: Patient was taught how to check their blood sugar.

Do: Patient was able to correctly return-demonstrate how to check their blood sugar.

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

Make sure the nursing note is current 

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

Do: Patient had a temperature of 39.1°C (102.4°F) at 0900. 

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: Patient had altered mental status, stomach pain, and could not recall their name.

Do: Patient had altered mental status with inability to recall their name and complained of dull stomach pain at a level of 5 out of 10.

Group related information together. 

Make sure the nursing note is professional 

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

Do: Patient refused 0900 meds. 

It is inappropriate to label patients 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.


Nursing Notes Template

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Nursing Cheat Sheet

Great nursing notes are clear, concise, correct, complete, relevant, current, sequential, legible, and secure.

Master the topic with a unique study combination of a concise summary paired with video lectures. 

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