Nursing Notes: Complete Documentation Guide with Examples
Master nursing documentation with this comprehensive guide. Learn SOAPIE, DAR, PIE, and narrative formats with real examples. Includes templates for assessments, progress notes, and shift reports that meet legal and regulatory requirements.
Why Nursing Documentation Matters
Nursing documentation is far more than a regulatory requirement—it's a critical component of patient safety, communication, and professional accountability. According to the American Nurses Association, nurses spend approximately 40% of their shift on documentation, making it one of the most time-consuming aspects of patient care.
Communication
Provides vital information to the healthcare team for safe, effective care
Decision Making
Supports clinical decisions for individual clinicians and the care team
Legal Protection
Creates a defensible record in case of malpractice claims or litigation
Regulatory Compliance
Meets requirements for credentialing, audits, and accreditation
Reimbursement
Documents severity of illness and intensity of care for proper billing
Quality Improvement
Provides data for tracking outcomes and improving care processes
The Golden Rule of Nursing Documentation
"If it wasn't documented, it wasn't done." This legal principle underscores why complete, accurate, and timely documentation is essential. Your notes are the only evidence that nursing care was provided.
Nursing Documentation Formats
Different formats serve different purposes. Understanding when to use each helps you document efficiently while meeting all requirements.
SOAPIE
Subjective, Objective, Assessment, Plan, Intervention, Evaluation
Extended SOAP format that includes nursing interventions and patient response evaluation
Best for: Comprehensive patient encounters, admission assessments, complex care situations
Subjective
Patient-reported symptoms, complaints, and feelings
Objective
Measurable data: vitals, assessments, lab values
Assessment
Nursing diagnosis and clinical judgment
Plan
Planned interventions and care approach
Intervention
Actions taken and treatments provided
Evaluation
Patient response to interventions
S: Patient reports "sharp, stabbing pain in my chest" rated 7/10, onset 2 hours ago while walking. Denies shortness of breath, nausea, or diaphoresis. States pain does not radiate. O: VS: BP 148/92, HR 88, RR 18, SpO2 98% RA, Temp 98.6°F. Alert and oriented x4. Skin warm, dry. Cardiac: regular rate and rhythm, no murmurs. Lung sounds clear bilaterally. 12-lead ECG: normal sinus rhythm, no ST changes. Troponin pending. A: Acute chest pain, etiology under investigation. Risk factors include HTN and family history of CAD. Current presentation atypical for cardiac ischemia but cannot be ruled out pending workup. P: Continuous cardiac monitoring. Serial troponins q6h x3. Obtain chest X-ray. Administer aspirin 325mg PO if not contraindicated. Notify MD of results. Pain management per protocol. I: Placed on continuous telemetry. 18G IV established in L forearm. Aspirin 325mg PO administered. Blood draw for troponin, BMP, CBC completed. Chest X-ray ordered. MD notified of patient status. E: Patient reports pain decreased to 4/10 after 30 minutes of rest. Vital signs stable. No ECG changes noted on monitoring. Awaiting lab results. Patient resting comfortably, call light within reach.
DAR
Data, Action, Response
Focus charting method that documents specific patient problems and nursing responses
Best for: Tracking specific issues during shifts, documenting problems and outcomes
Data
Objective and subjective information about the focus/problem
Action
Nursing interventions performed
Response
Patient outcome and response to actions
Focus: Pain Management D: Patient grimacing and guarding abdomen. Reports pain level 8/10 in RLQ, described as "constant aching with sharp spikes." Last pain medication (morphine 4mg IV) given 4 hours ago. Patient states "I need something for this pain, I can't rest." A: Assessed pain using numeric scale. Verified last dose timing in MAR. Administered morphine 4mg IV push per PRN order. Repositioned patient to left side with pillow support. Dimmed lights and minimized disruptions. Set up PCA education for physician order if needed. R: Patient reports pain decreased from 8/10 to 4/10 within 15 minutes of medication administration. Able to rest quietly. Facial grimacing resolved. Will continue to monitor q2h and notify MD if pain remains uncontrolled for PCA consideration.
Narrative
Chronological Narrative Notes
Free-form documentation in chronological order describing events and care provided
Best for: Detailed shift documentation, unusual events, situations requiring extensive explanation
Time
Document events chronologically with timestamps
Event
Describe what occurred or was observed
Action
What was done in response
Outcome
Results of actions taken
0700: Received report from night shift RN. Patient is post-op day 2 following laparoscopic cholecystectomy. Night was unremarkable with adequate pain control on PO medications. Last BM 3 days ago. 0730: Performed head-to-toe assessment. Patient alert and oriented, in no acute distress. Surgical sites clean, dry, intact with steri-strips in place. Bowel sounds hypoactive x4 quadrants. Lungs clear. Ambulated to bathroom with assistance, voided 250mL clear yellow urine. 0830: Administered scheduled medications: acetaminophen 1000mg PO, docusate 100mg PO. Patient tolerated clear liquid breakfast without nausea. 0930: Patient ambulating in hallway with steady gait. Encouraged deep breathing exercises and use of incentive spirometer. Patient demonstrated 1500mL capacity x10 reps. 1100: MD rounds. Order received to advance diet to regular, discontinue IV fluids when tolerating PO intake. Discharge teaching initiated regarding wound care, activity restrictions, and warning signs. 1200: Patient ate 75% of regular lunch without difficulty. IV saline lock converted. Teaching reinforced with written instructions provided. Family present and verbalized understanding of post-discharge care.
PIE
Problem, Intervention, Evaluation
Problem-oriented charting that focuses on identified nursing problems
Best for: Tracking nursing diagnoses, care plan documentation
Problem
Identified nursing diagnosis or patient problem
Intervention
Nursing actions taken to address the problem
Evaluation
Assessment of intervention effectiveness
Problem: Risk for falls related to post-operative sedation and weakness as evidenced by unsteady gait and need for assistance with ambulation. Intervention: Bed in lowest position with side rails x2 up. Call light within reach; patient instructed on use. Yellow fall risk bracelet applied. Fall risk sign posted. Non-skid footwear provided. Assisted patient to bathroom x3 this shift using gait belt. Physical therapy consulted for mobility assessment. Scheduled pain medication 30 minutes before ambulation to optimize comfort and participation. Evaluation: Patient ambulated to bathroom and 50 feet in hallway with one-person assist using gait belt. Gait steadier than previous shift. No falls or near-falls this shift. Patient verbalized understanding of fall precautions and consistently used call light before attempting to stand. Fall risk score: 55 (moderate risk) - unchanged from admission. Continue current fall prevention interventions.
Types of Nursing Documentation
Different clinical situations require different types of notes. Here's what to include in each.
Admission Assessment
Comprehensive baseline evaluation when patient is admitted
Key Elements:
- Chief complaint and history of present illness
- Past medical/surgical history
- Medications and allergies
- Head-to-toe physical assessment
- Vital signs and pain assessment
- Psychosocial assessment
- Skin assessment with Braden score
- Fall risk assessment (Morse scale)
- Nutritional screening
- Advance directives status
Pro Tip:
Be thorough but efficient. This note establishes the baseline against which all progress is measured.
Shift Assessment
Documentation of patient status at beginning and throughout shift
Key Elements:
- Focused head-to-toe assessment
- Vital signs with comparison to baseline
- Pain assessment (level, quality, location)
- IV site assessment and fluid status
- Intake and output
- Skin and wound assessment
- Activity level and mobility
- Mental status and orientation
Pro Tip:
Document changes from previous assessment. If unchanged, note "no change from previous assessment" rather than copying.
Progress Notes
Ongoing documentation of patient status and response to treatment
Key Elements:
- Current patient status
- Response to interventions
- New symptoms or concerns
- Physician communication
- Patient/family teaching
- Goals and outcomes progress
Pro Tip:
Write progress notes when there is a significant change, intervention, or at minimum every 4 hours for acute care.
Medication Administration
Documentation of all medications given
Key Elements:
- Drug name, dose, route, time
- Indication/reason if PRN
- Patient identification verified
- Assessment before medication (pain level, vitals if applicable)
- Patient response/effectiveness
- Any adverse reactions
Pro Tip:
Document at time of administration. For PRN meds, always document effectiveness within the appropriate timeframe.
Procedure Notes
Documentation of nursing procedures performed
Key Elements:
- Procedure performed
- Indication for procedure
- Consent verified if applicable
- Sterile technique maintained
- Findings (drainage, appearance, etc.)
- Patient tolerance
- Complications or concerns
Pro Tip:
Be specific about technique used and patient response. This protects both patient and nurse.
Discharge Notes
Summary of hospitalization and discharge instructions
Key Elements:
- Discharge disposition and mode
- Condition at discharge
- Discharge medications reviewed
- Follow-up appointments
- Warning signs to watch for
- Patient/family teaching completed
- Understanding verified (teach-back)
- Paperwork provided
Pro Tip:
Document that patient verbalized understanding. Include who was present for teaching.
Documentation by Care Setting
Each care setting has unique documentation requirements and priorities.
ICU/Critical Care
Focus: Detailed hemodynamic monitoring, ventilator settings, drips, hourly neuro checks
Frequency: Hourly or more frequent documentation
Medical-Surgical
Focus: Routine assessments, medication administration, patient teaching, discharge planning
Frequency: Minimum every 4 hours, more with changes
Emergency Department
Focus: Rapid assessment, triage, interventions, frequent reassessment
Frequency: Continuous during active treatment
Labor and Delivery
Focus: Fetal monitoring, labor progress, maternal status
Frequency: Per stage of labor protocols
Home Health
Focus: Skilled nursing visits, patient self-management, home environment
Frequency: Each skilled visit
Long-Term Care
Focus: Ongoing condition monitoring, ADL assistance, regulatory compliance
Frequency: Per shift minimum, with MDS schedules
Common Documentation Mistakes to Avoid
These frequent errors can lead to patient safety issues, legal liability, and audit failures.
Using vague or subjective language
Avoid:
Patient had a good night.
Better:
Patient slept 6 hours with two interruptions for medication administration. Denies pain or discomfort. Vital signs stable throughout shift.
Why it matters: Vague language is open to interpretation and does not convey useful clinical information.
Late documentation or documenting in advance
Avoid:
Writing notes at end of shift from memory or documenting before performing assessment.
Better:
Document as close to real-time as possible, using timestamps accurately.
Why it matters: Late documentation increases errors and may be questioned legally. Pre-documentation is falsification.
Copy-paste without modification
Avoid:
Copying previous shift assessment verbatim without actually reassessing.
Better:
Perform fresh assessment each time and document actual findings, even if similar.
Why it matters: Copy-paste errors can lead to missed changes in patient condition and legal liability.
Documenting opinions or judgments
Avoid:
Patient was being dramatic about pain.
Better:
Patient reported pain level 9/10 with crying and moaning. Vital signs stable. Administered prescribed analgesic.
Why it matters: Documentation should be objective. Judgmental language is unprofessional and legally risky.
Using unapproved abbreviations
Avoid:
Pt. c/o SOB x 2d, tx w/ O2.
Better:
Patient complained of shortness of breath for 2 days, treated with supplemental oxygen.
Why it matters: Unapproved abbreviations can be misinterpreted. Use only facility-approved abbreviation lists.
Failing to document patient teaching
Avoid:
Assuming teaching is implied when giving medications.
Better:
Educated patient on purpose of metoprolol (blood pressure control), potential side effects (dizziness, fatigue), and importance of not stopping abruptly. Patient verbalized understanding and asked appropriate questions.
Why it matters: Teaching documentation demonstrates standard of care and patient engagement.
Not documenting communication with providers
Avoid:
Calling the doctor but not documenting the conversation.
Better:
SBAR communication to Dr. Smith at 1430 regarding patient's new-onset confusion. Orders received for stat BMP and CT head. Orders read back and confirmed.
Why it matters: Provider communication is critical to continuity of care and legal protection.
Leaving blanks or incomplete documentation
Avoid:
Skipping sections of the flowsheet or leaving assessment areas blank.
Better:
Complete all required fields. If unable to assess, document why (e.g., "patient refused" or "unable to assess due to sedation").
Why it matters: Incomplete documentation suggests incomplete assessment and creates legal vulnerability.
Common Nursing Abbreviations
Use only facility-approved abbreviations. Avoid those on the "Do Not Use" list (e.g., U for units, QD for daily). Here are commonly accepted abbreviations:
Do Not Use List (Joint Commission)
Never use: U (write "units"), IU (write "international units"), Q.D./QD (write "daily"), Q.O.D./QOD (write "every other day"), trailing zeros (write "1 mg" not "1.0 mg"), lack of leading zero (write "0.5 mg" not ".5 mg").
Nursing Note Template
Use this SOAPIE template as a starting point for comprehensive nursing documentation.
NURSING PROGRESS NOTE (SOAPIE FORMAT) ===================================== Date: [Date] Time: [Time] Shift: [Day/Evening/Night] Patient: [Name] MRN: [Number] Room: [Number] SUBJECTIVE ---------- Chief Complaint: Patient Statements: Pain Assessment: [ ] Location _____ Intensity ___/10 Quality _____ Current Symptoms: OBJECTIVE --------- Vital Signs: BP ___/___ HR ___ RR ___ Temp ___ SpO2 ___% on ___ Level of Consciousness: [ ] Alert [ ] Oriented x ___ Neurological: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Skin/Wounds: IV Site Assessment: Intake: _____ mL Output: _____ mL ASSESSMENT ---------- Nursing Diagnosis/Clinical Impression: Risk Factors: Progress Toward Goals: PLAN ---- Planned Interventions: Monitoring: INTERVENTION ------------ Actions Taken This Shift: Medications Administered: Procedures Performed: Teaching Provided: EVALUATION ---------- Patient Response to Interventions: Current Status: Follow-up Needed: Nurse Signature: _________________________ RN Date/Time: ___________
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Try PatientNotes FreeFrequently Asked Questions
What is the best format for nursing notes?
The best format depends on your facility and situation. SOAPIE is comprehensive for complex assessments, DAR (focus charting) is efficient for tracking specific problems, and narrative notes work well for detailed shift documentation. Most facilities use a combination based on the documentation type.
How often should nurses document?
Documentation frequency varies by setting. ICU requires hourly or more frequent notes, medical-surgical units typically require documentation every 4 hours minimum, and documentation is always required with any significant change in patient condition, new orders, or interventions.
What should I do if I make a mistake in my notes?
Never use white-out, scribble out, or make entries illegible. For paper charts: draw a single line through the error, write "error" above it, initial and date. For electronic records: follow your facility's amendment policy—most EHRs have late entry or addendum functions.
Can I document on behalf of another nurse?
Generally no. Each nurse should document their own assessments and care. If you must document for another nurse (rare circumstances), clearly indicate who performed the care and who is documenting. Always follow your facility policy.
What if I forget to document something during my shift?
Write a late entry as soon as you remember. Label it clearly as "Late Entry" with the current date/time and the date/time of the event being documented. Explain why the documentation was delayed if appropriate.
How detailed should nursing notes be?
Notes should be thorough enough to paint a clinical picture but concise enough to be efficient. Include all relevant findings, changes in condition, interventions, and patient responses. Avoid excessive detail that doesn't impact care.
Are nursing notes part of the legal medical record?
Yes. Nursing documentation is part of the permanent medical record and can be subpoenaed for legal proceedings. Courts view documentation as the best evidence of care provided—if it isn't documented, it may be assumed it wasn't done.
How long should nursing documentation be retained?
Retention requirements vary by state and record type. Most states require adult records be kept 7-10 years from the last encounter. Pediatric records typically must be kept until the patient reaches age of majority plus additional years (often until age 21-28).
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