Do you want to go from being a great nurse to an exceptional nurse? Learning to write nursing notes accurately, thoroughly and efficiently can help you do that. While nursing documentation is important, creating efficiencies can also allow you to spend more time providing care to your patients.
But first, let’s learn what nursing notes are, why nursing notes are important and how to write a good nursing note while looking at nursing notes documentation examples.
In This Article:
- What Are Nursing Notes, and Why Are They Important?
- Nursing Notes and Charting
- How To Write Good Nursing Notes
- Nursing Notes Examples
- Who Uses Nurses Notes?
- Do Nursing Notes Vary Between Patients?
- What About Different Nursing Note Requirements?
- Take Credit for Your Quality Care With Nursing Notes
What Are Nursing Notes, and Why Are They Important?
Nursing notes are a crucial part of the patient's medical record. Some facilities still use pen and paper for documentation, but more modern patient records are almost entirely stored in an electronic medical record (EMR).1 EMRs are mandated as part of the Affordable Care Act and must provide “meaningful use” of vital patient data and information.2
Nursing notes include the physical assessments, interventions and observations made by the nurse and provide an overview of the patient's health status. Accurate and timely nursing notes are essential for tracking changes in a patient's condition, evaluating the effectiveness of interventions and promoting patient safety through a holistic and well-documented approach to healthcare.
Nursing notes also contribute to care planning, facilitate collaboration among interdisciplinary teams and serve as a legal record, enhancing accountability and compliance. These records are important for communication among healthcare professionals, ensuring continuity of care.
Nursing Notes and Charting
Nursing notes are a part of charting. Charting refers to the entire medical record, including the patient's medical history, diagnoses, treatment plans and other relevant details. It does so in a systematic and organized manner, allowing healthcare providers to track the patient's medical history, monitor changes in health over time and make informed decisions regarding their care.
Nurses explicitly write nursing notes and document patient care during hospital or other healthcare facility stays. Nursing notes facilitate communication, ensure continuity of care and provide a comprehensive record of a patient's condition and the nursing interventions performed. Nursing notes can include documentation of assessments, interventions, responses to interventions, patient education, changes in patient condition, communication with the care team, medications and nutritional status.
How To Write Good Nursing Notes
The most important part of writing good nursing notes is to be consistent. Identify your process for documentation and build in a habit of writing your notes accurately, timely, thoroughly and efficiently while in nursing school. Also remember not to include hearsay, opinions or activities other care teams or family members perform. If you do receive outside information that might be valuable, always use quotations.
Here are some important steps when writing a nursing note:
- Make sure you verify the correct patient’s chart.
- Use nursing notes to tell the patient’s story.
- Only chart activities you performed or things you witnessed.
- Take notes in real-time or as close as reasonably possible. (If you must document late, include “late entry,” when the action happened, and when you are recording it.)
- Use complete phrases to avoid misinterpretation of your notes.3
- Chart your safety checks and safety measures in place to protect the patient if not documented elsewhere in the chart.
Two common acronyms to remember how to write nursing notes are SOAPIE — Subjective, Objective, Assessment, Plan, Intervention, Evaluation — and DAR — Data, Action and Response. Either is acceptable as long as your hospital or facility allows and you follow the rules of being accurate, thorough and efficient in using them.4,5
Nursing Notes Examples
Below are some examples of nursing notes collected using the SOAPIE and DAR acronyms. It can be helpful to review examples such as these when establishing your own system of nursing note-taking.
Patient: Jane Doe, 42-year-old female, s/p upper respiratory infection
Date: December 1, 2023
1030: S: Patient reports productive cough and fatigue while sitting in the chair. O: Most recent vitals: heart rate 105, respiratory rate 24, blood pressure 125/85, oxygen saturation 89%. On auscultation, this nurse noted faint crackles in bilateral lower lungs. A: The patient is experiencing mild impaired gas exchange due to recent pneumonia and secretions. P: Use incentive spirometer (IS) ten times every hour, continue pulmonary toilet, notify respiratory therapy for nebulizer treatment, assist with ambulation four times daily.
1145: I: Patient demonstrated incentive spirometer accurately and performed x 10. Patient able to walk 200 feet with minimal assistance. O2 sats remained >90% on room air while walking.
1505: E: Respiratory treatment completed. O2 saturation is 95% on room air. The patient is resting comfortably in the chair. Denies pain and shortness of breath. Continue to monitor vital signs and encourage IS. Bed and monitor alarms are on.
Patient: John Doe, 62-year-old male, s/p bilateral knee replacement
Date: December 1, 2023
1425: D: Upon assessment, the patient reports pain 6/10. Bilateral dressings are clean, dry and intact. Range of motion is improved from previous assessment. Most recent vitals: heart rate 99, respiratory rate 24, blood pressure 140/82, oxygen saturation 97% on room air. A: Pain medications administered as ordered, see medication record. Ice applied as ordered, plan for 10 minutes. Scheduled to work with the physical therapist (PT) in 30 minutes.
1555: R: Patient reports pain is now 2/10. Patient states, “I think my therapy will go well today.” PT in room with patient, gait belt is on.
Who Uses Nurses Notes?
Nursing notes are a vital part of the patient record. The entire care team, including other nurses, providers and technicians use nursing notes and rely on them to follow patient progress, status and plan. Care team members may need to review what goals have been met and what tasks still need to be achieved. Nursing notes help others to develop their care plan for the patient.
Insurance companies also use and may have access to relevant medical records, including nursing notes, to authorize payment for treatment. They may scrutinize the nursing note to ensure the care is authorized correctly and payment for services is accurate and adequate for the patient. The common saying goes: “If it wasn’t documented, then it didn’t happen.”
Lawyers, as much as you’d hate to be involved in a legal situation, can access nursing notes with permission.6 This can happen if there is a question about the quality of a patient's care. It’s a good idea to write your nursing notes, remembering that anyone with legal authorization can see a patient’s record, including other healthcare providers, insurance companies and the patient themselves.
Do Nursing Notes Vary Between Patients?
When caring for a patient with failing health, you may think about providing more or less documentation. Sticking to a systematic way of charting, regardless of the patient’s condition or status, ensures that you don’t miss the most important parts of their care.
What About Different Nursing Note Requirements?
You may have different nursing documentation requirements depending on where you work or the type of facility. Some systems have checkbox and radio-button systems to chart patent assessments, while others rely entirely on narrative-style documentation. Be sure you understand your institution's documentation regulations.
Take Credit for Your Quality Care With Nursing Notes
Now you know how to write nursing notes and understand the importance of nursing notes for documentation to show the quality of care you provide. Accurate and timely documentation is crucial for effective communication among healthcare providers, ensuring patient safety and meeting regulatory and legal requirements. Practice good nursing note-taking and use these other tips to succeed in nursing school.
In Grand Canyon University’s accelerated Bachelor of Science (ABSN) program, you’ll get experience writing nursing notes in practical healthcare and clinical settings. Check out GCU’s College of Nursing and Health Care Professions to get started on earning your ABSN in as few as 16 months.7 Fill out the form on this page to learn more and get started today.
1 Practice Fusion. (2015, Dec. 18). Electronic Nursing Notes. Retrieved on Nov. 27, 2023.
2 Centers for Medicare & Medicaid Services. (n.d.). Certified EHR Technology. Retrieved on Nov. 27, 2023.
3 Nurses Service Organization. (n.d.). Abbreviations in Documentation: A shortcut to disaster for Nurses. Retrieved on Nov. 27, 2023.
4 AllNurses. (2023, Jan. 28). How to make a soapie note. Retrieved Nov. 27, 2023.
5 Lukey, A. (2023, March 7). Nursing Notes: How to write them (with Examples). NurseTogether. Retrieved on Nov. 27, 2023.
6 Nurses Service Organization. (n.d.). Do’s and Don’ts of Nursing Documentation. Retrieved Nov. 27, 2023.
7 Secondary applicants must transfer a minimum of 60 of the required 123 credits or have completed a baccalaureate degree which includes nine prerequisite courses/labs and 10 general education courses prior to starting the core nursing courses, which can be completed in as few as 16 months. Direct entry applicants that do not transfer 60 credits but meet the minimum requirements can complete these credits through GCU prior to starting the core nursing courses. Depending on the state where student has enrolled or intends to complete the program, student may require additional courses. This may include, but is not limited to, additional general education courses, courses in the major, clinical courses or a different course sequence. See University Policy Handbook.
Approved by the College of Nursing and Health Care Professions on Dec. 18, 2023.
The views and opinions expressed in this article are those of the author’s and do not necessarily reflect the official policy or position of Grand Canyon University. Any sources cited were accurate as of the publish date.