Although nursing documentation may at times seem overwhelming, it is a key part of nursing practice. Colloquially known as “charting,” nursing documentation provides a record of nursing care provided to a patient, family, or community. Charting and, more specifically, nursing notes, allow nurses to demonstrate that the care they provided was ethical, safe, and informed by relevant nursing knowledge.
In this article:
- Nursing Notes vs. Charting
- How Are Nursing Notes Used?
- How to Write Good Nursing Notes (What’s included)
- Nursing Note Examples
- General Advice on Writing Nursing Notes
Nursing Notes vs. Charting
Charting is a nursing process that includes all the documentation required from nurses. This might include legal, professional, and institution-specific requirements. Some examples of charting include documenting medications administered, vital signs, physical assessments, and interventions provided. Nursing notes are a narrative written summary of a given nursing care encounter. This might include a description of a nursing visit, a specific care event, or a summary of care. A nurse’s note is a form of charting that describes the nurse’s decision-making process regarding the nursing care provided.
Nursing notes are an important part of high-quality nursing documentation because they provide an opportunity for nurses to demonstrate their nursing knowledge and communicate the nursing process to other team members of the patient’s interprofessional care team.
How Are Nursing Notes Used?
A clear and comprehensive nursing note serves several purposes in nursing practice, both in patient care and to provide legal protection to the nurse writing the note. Reasons to write high-quality nursing notes include:
- Contributing to continuity of care for patients. Continuous care requires that the care provided to the patient is well-organized and that there is cooperative communication between nurses and other interdisciplinary team members. Continuous care contributes to patient-centered and safe care. Nursing notes allow all people on the care team to understand the patterns of patient care.1
- Communicating care goals. Nursing notes are one place where the nurse can share the plan of care with team members. Nursing notes also allow others to see what interventions have been performed so far and what the outcome of those interventions were.
- Demonstrating the nurse’s knowledge as required by professional regulators. Nursing notes are useful for demonstrating the knowledge, skill, and judgment required by the nurse’s professional regulators, such as their college. In addition, if there is ever a concern about a nurse’s license, nursing notes can be used as evidence of competent and safe practice in line with professional standards of practice.
- Contribute to quality improvement. Quality improvement projects across nursing settings may include a review of charts to understand the care process. Nursing notes that accurately and comprehensively reflect care delivered allow for more precise quality improvement initiatives.
- Contribute to nursing research. Nursing research projects may include a review of the chart. Similar to quality improvement initiatives, nursing notes that accurately reflect the care provided allow accurate research data to be collected.
- Legal protection. Nursing notes are included in the patient/client’s permanent medical record. In the case of legal action related to care that a nurse provided or was involved in, nursing notes demonstrating that ethical and competent nursing care was delivered provide legal protection to the nurse.
- Reimbursing insurance claims. In some jurisdictions, insurance or other healthcare payers may directly reimburse nursing care. The nursing note may describe the rationale for reimbursable nursing activities in this case.
These are just a few key reasons nurses should spend time and effort writing high-quality nursing notes.
How to Write Good Nursing Notes (What’s included)
Different work settings may have an expected format or even templates for nursing notes. However, all nursing notes should include evidence of the nursing process. There are different templates for what should be included in a nursing note. Institutional or hospital policies may be in place on what should be included in the nursing note. However, it is the individual nurse’s responsibility and a demonstration of nursing knowledge and judgment to decide what information is relevant or irrelevant for the nursing note.
Nurses’ notes usually include subjective (what the patient tells you) and objective (assessment/analysis) data. However, the nurse should be careful not to include judgements or their own opinion in nursing notes. It is important to include subjective data. However, subjective data should be written in quotation marks as statements made by the patient rather than objective facts.
Two common templates for nursing notes use the mnemonics DAR and SOAPIE. Rather than absolute rules that describe how a nursing note should be structured, these two mnemonics are to be used as guidelines and to help the nurse remember what information should be included in their note.
SOAPIE: subjective (what the patient tells you), objective (the nurse’s assessment), analysis (interpretation of data), plan (what the nurse plans to do), implementation (what was done) and evaluation (how did the intervention work?)
DAR: Data (both subjective and objective), action (what was done), response (how did the patient respond?
There are other acceptable templates for nursing notes. The nurse should check with their institution if there is a preferred or institution-specific policy regarding what should be included in the nursing note. Overall, what must be included in the nursing note is the nurse’s own name, the name of the patient/client, the date and time of the note, and a demonstration of the appropriate nursing process. Nursing notes should also be made in chronological order.
When writing a nursing note regarding a consultation with another healthcare provider, the nurse should include the name and designation of the other healthcare provider in addition to other components of the nursing note.
Nursing Note Examples
In the following section you will find nursing note examples for the SOAPIE as well as for the DAR format.
Patient: Jane Doe
Date: January 30, 2023
13:17: Patient reports pain to lower abdomen, rates pain at 7/10. She states that the pain has been increasing over the past half hour after her return from PACU. Mrs. Doe describes the pain as a “dull ache.” (Subjective) Abdominal dressing is dry and intact. Bowel sounds are hypoactive X4. Most recent vital signs BP 114/82, HR 88, respiration 18, Sp02 94% on room air. (Objective) Patient experiencing post-operative pain related to recent hernia operation. (Analysis) Writer will offer patient education regarding PCA usage. (Plan)
13:26: Writer reminded the patient about how to use the button on her PCA to control her pain. Writer educated patient on the importance of managing post-surgical pain early to maintain comfort. (Intervention)
13:57 Reassessed patient pain after PCA education. Patient now describes that her pain is “subsiding.” When rating her pain on the pain scale, patient now describes her pain as 2/10 which is acceptable to her. (Evaluation)
This note includes all elements of the SOAPIE note and also is written at the time in which the activity was performed so there is a clear sequence of events.
Patient: Jill Doe
Date: January 30, 2023
0927: On assessment patient described increased shortness of breath related to her chronic asthma. Patient stated that she “uses her inhaler at home when I get short of breath.” Patient respiration rate 22, Sa02 92% on room air, wheeze audible on auscultation of lungs. (Data) Writer administered 2 puffs (34 mcg) of patient’s Ipratropium PRN inhaler. (Action) Patient states that shortness of breath now resolved. (Response)
General Advice on Writing Nursing Notes
Writing high-quality nursing notes is a skill like any other nursing skill that takes time and focused effort to improve. With practice, nursing notes will become second nature as one pillar of safe and effective clinical practice. Here are a few quick practice pointers to improve your nursing notes.
- If you are using paper charting, ensure that the writing is legible. Illegible charting does not accomplish the goal of communicating care to the team and will not legally protect the nurse.
- Include both subjective and objective data. Including both subjective and objective data in the nursing note creates a comprehensive clinical picture.
- Remember to document significant interactions with family members, significant others, or substitute decision-makers. This might include interactions such as a family member describing the patient’s medical history when the patient is unable to do so themselves.
- Limit your use of abbreviations. If you do use abbreviations, ensure that they are allowed for your institution
- Document as soon as possible after the care interaction. It is preferable to document the care interaction as soon as possible. If the nurse waits to document, they may forget important details.
- If an error is made in documentation, do not delete, white-out, or attempt to erase the error. Instead, document that the first entry was made in error by drawing a line through and initialing for paper charting or following the correct procedure for the electronic medical record.
- For paper charting, use only black or blue ink, which is accepted in legal proceedings and is the easiest to read.
- Read other documentation on the patient! This could include other members of the interprofessional team or nurses’ notes on the patient. These notes may include helpful information that may inform your care of the patient. However, a word of caution is that the nurse should never rely on another’s assessment. Always double check the details of the patient’s history and make your own assessment.
To ensure high-quality nursing notes, the nurse might ask themselves if their note adequately answers the following question: “If another nurse were to take over this assignment, without a verbal handover, is there enough information here that they could provide safe and continuous care for this patient?”2 If the answer is no, the nurse might consider that more detail ought to be provided.
- College of Nurses of Ontario. Documentation, Revised 2008. Published online 2008. Accessed January 28, 2023. https://www.cno.org/globalassets/docs/prac/41001_documentation.pdf
- College of Registered Nurses of Manitoba. Documentation Guidelines for Registered Nurses. Accessed January 28, 2023. https://crnm.mb.ca/wp-content/uploads/2022/01/Documentation-Guidelines-for.pdf