Reference · Nursing documentation

Nursing notes: examples and how to write them

What a nursing note should contain, how narrative, SOAPIE, DAR, PIE and charting by exception compare, five fictional nursing note examples (respiratory change, post-op, fall risk, pain reassessment and behavioral health), and the documentation do's and don'ts.

Want to see an AI-drafted Medical SOAP note? Open a fictional medical visit note in the MentalNote editor, no sign-up needed.

Checked on 23 October 2026. General information, not clinical or legal advice: follow your facility's documentation policy. All examples are fictional.

What are nursing notes?

Nursing notes (also called nurses' notes or nursing progress notes) are the nurse's entries in the patient record: what you assessed, what care you gave and how the patient responded. They carry information between shifts and disciplines, show changes in condition and who was told, and are part of the legal medical record.

In most hospitals, routine findings go on flowsheets (vital signs, intake and output, scheduled assessments) and the nursing note records what a flowsheet cannot: a change in condition, an event, an intervention and its result, a conversation with the provider, or education given. Your facility's policy decides which format you use and what goes where.

What to include in a nursing note

Date and time. The time of the entry and, if different, the time of the event. Sign with your name and credentials as your facility requires.
Assessment findings. Measured values (vital signs, oxygen saturation and the oxygen delivery device, intake and output) and what you observed, with the pain score and the scale used.
The patient's own words. Put subjective statements in quotes: "My chest feels tight" says more than "patient anxious".
Interventions. What you did and when, including PRN medications (name, dose, route, time, reason) as recorded on the medication administration record (MAR).
Notifications. Who you notified, when, what you reported and the response, including any orders received and read back.
Response and reassessment. How the patient responded and when you reassessed. An intervention without a recorded response is a gap.
Education and safety. What you taught and how the patient showed understanding (for example teach-back), and safety measures in place.
Objective language. "Ate about 25% of breakfast" rather than "poor appetite"; "shouting and pacing the hallway" rather than "aggressive".

Nursing note formats compared

The five charting formats nurses meet most often. Many facilities combine one of them with flowsheets.

Common nursing documentation formats
Format	Sections	Typical use	Watch out for
Narrative	Free text in time order	Events, changes in condition, unusual situations; often alongside flowsheets	Can get long and unfocused; easy to leave out the patient's response
SOAP / SOAPIE / SOAPIER	Subjective, Objective, Assessment, Plan, plus Intervention and Evaluation (and Revision)	Problem-oriented records; one note per problem	Plain SOAP can omit what the nurse did and how the patient responded; SOAPIE adds both
DAR (focus charting)	Focus, then Data, Action, Response	A focus can be a nursing diagnosis, a problem, a concern, an event or a change in condition	Keep the focus specific; Data holds both subjective and objective findings
PIE	Problem, Intervention, Evaluation	Used with a separate assessment flowsheet; problems are numbered and referred to by number	Assessment data sit in the flowsheet, so the note alone may not show them
Charting by exception (CBE)	Only findings that differ from defined normal standards	Units with well-defined normal parameters and flowsheets	Depends on clear written standards; a missed exception leaves no record of the finding

SOAP, DAR and PIE are also used outside nursing; see the PIE notes guide for how therapists use PIE, and the Medical SOAP note generator for SOAP notes in medical visits.

Nursing note examples

Five fictional, shortened examples for illustration (no real patients). Medications and doses are shown as if given under an existing order; they are not treatment guidance. Follow your orders, protocols and facility policy.

1. Medical-surgical: change in respiratory status (DAR)

Fictional example: DAR note, adult with pneumonia

Focus

Decreased oxygen saturation, shortness of breath.

Data

0215. 68-year-old admitted 2 days ago with community-acquired pneumonia. Awake, states "I can't catch my breath." RR 26, SpO2 88% on 2 L/min nasal cannula, HR 104, BP 132/78, T 100.9 F (38.3 C). Crackles in the right lower lobe; using accessory muscles. Alert and oriented.

Action

0215: head of bed raised to 45 degrees. Oxygen increased to 4 L/min nasal cannula per the existing titration order, which specifies a target SpO2 of 94-98%. Continuous pulse oximetry applied; remained at bedside to reassess breathing and oxygen saturation. 0220: notified the covering provider by phone using SBAR (Situation, Background, Assessment, Recommendation); orders received for a portable chest X-ray and an arterial blood gas, read back and confirmed. 0225: acetaminophen 650 mg PO given per PRN order for temperature. Coached pursed-lip breathing.

Response

0220: SpO2 94% on 4 L/min nasal cannula, RR 24; accessory-muscle use decreased. These findings and the initial deterioration reported to the covering provider. 0250: RR 22, SpO2 95% on 4 L/min nasal cannula, HR 98; awake, no accessory-muscle use. States "It's a little easier now." Chest X-ray done 0305; arterial blood gas drawn by respiratory therapy 0310. Results pending, with the covering provider to review when available. Continuous pulse oximetry and respiratory reassessment continued per orders; escalate promptly for renewed distress or saturation below the prescribed target.

2. Post-operative: pain and neurovascular checks (SOAPIE)

Fictional example: SOAPIE note, postoperative day 1 after right total knee arthroplasty

"My knee is about a 6 out of 10, worse when I bend it." Denies nausea, calf pain, numbness or tingling.

0800. T 99.1 F (37.3 C), HR 84, BP 128/74, RR 16, SpO2 96% on room air. Pasero Opioid-induced Sedation Scale (POSS) 1, awake and alert. Right knee dressing dry and intact. Right foot warm and pink, capillary refill under 3 seconds, dorsalis pedis pulse palpable, moves toes, sensation intact. Voided 350 mL at 0700. Incentive spirometer 1,250 mL.

Acute pain related to the surgical procedure. Right lower extremity neurovascular status intact.

Give PRN analgesia before physical therapy, ice and elevation per order, continue neurovascular checks per protocol.

0810: oxycodone 5 mg PO given per PRN order for pain 6/10. Ice pack applied to the right knee over a cloth barrier. Reinforced incentive spirometer use 10 times an hour while awake.

0900: pain 3/10 on the 0-10 numeric scale. POSS 1, awake and alert; RR 16, breathing unlabored, SpO2 96% on room air. Denies dizziness or nausea. Walked 30 feet with a walker and the physical therapist. Neurovascular checks unchanged.

3. Fall risk (PIE)

Fictional example: PIE note, older adult with established cognitive impairment

Risk for falls related to established cognitive impairment and unsteady gait. Morse Fall Scale score 65 (high risk on this unit's tool). 2230: found sitting on the edge of the bed, attempting to stand without help; no fall. States "I need the bathroom." Oriented to person only, unchanged from the documented baseline; no acute change in attention or alertness observed.

Assisted to the bathroom with a gait belt and one staff member. Bed returned to the lowest position and locked; bed alarm on; call light, urinal and water within reach; nonskid socks on. Reoriented to the room and the call light. Toileting offered every 2 hours while awake. Charge nurse informed; fall-prevention plan of care updated.

0030: resting in bed, bed alarm on, no further attempts to get up alone. Used the call light once at 0015 to ask for water. Continue fall precautions and reassess per protocol.

4. Pain reassessment (narrative)

Fictional example: narrative note, adult with suspected kidney stone

1400

Reports left flank pain 8/10 on the 0-10 numeric scale, sharp and constant, radiating to the left groin. Grimacing, guarding the left side. HR 102, BP 148/88, RR 20. Alert.

1405

Morphine 4 mg IV given per PRN order for severe pain (7-10). Reminded to call before getting up.

1435

Reassessed 30 minutes after the IV dose: pain 4/10, "It's dulled down." RR 16, HR 88, BP 136/82, SpO2 97% on room air. Pasero Opioid-induced Sedation Scale (POSS) 1, awake and alert. Urine strained per order; no stone seen. Call light within reach.

Facility policies set the reassessment time after a PRN analgesic, commonly within 15 to 30 minutes after an IV dose and 30 to 60 minutes after an oral dose. Record the time, the score, sedation level and respiratory status, not just "effective".

5. Behavioral health: agitation on an inpatient unit (DAR)

Fictional example: DAR note, inpatient psychiatric unit

Focus

Anxiety and agitation.

Data

1930. 29-year-old pacing the hallway, fists clenched, voice raised. States "Everyone here is against me. I need to leave." No physical aggression toward others or property. When asked, denies suicidal ideation and homicidal ideation; denies hearing voices.

Action

Approached calmly with a second staff member at a distance; used verbal de-escalation and offered the quiet room, which was accepted. Offered PRN medication per order; lorazepam 1 mg PO accepted at 1940. Every-15-minute safety checks continued per unit order.

Response

2010. Sitting in the quiet room, speaking at normal volume, hands relaxed. States "I feel calmer. I just want to call my sister." Phone call arranged per unit rules. No further pacing at 2030. Continue observation per order.

Notice what the examples share: exact times, measured values, the patient's own words, who was notified, and a reassessment that closes the loop. For the shorthand used above, such as SpO2, PRN, PO and IV, see medical abbreviations for SOAP notes.

Nursing documentation do's and don'ts

Do

Chart in real time or as soon as possible, and record the actual time of each finding and action.
Describe, don't label. Record what you saw and heard ("refused breakfast, stated 'I'm not hungry'") rather than conclusions ("noncompliant").
Record notifications in full: who, when, what you reported, what they said, and any orders read back.
Close the loop: every intervention should have a recorded response or reassessment.
Mark late entries clearly. Write "late entry", the current date and time, and the date and time the entry refers to. Never backdate.
Correct errors the approved way. In an electronic record, use the amend or correction function so the original stays visible. On paper, draw a single line through the error, mark it as an error per policy, and initial and date it; never erase, use correction fluid or obliterate text.

Don't

Don't leave blank lines or spaces in a paper chart; draw a line through unused space so nothing can be added later.
Don't chart ahead or for someone else. Document only care you gave or saw, after it happened.
Don't use vague words such as "good day", "appears comfortable", "tolerated well" or "normal" without specifics.
Don't use "Do Not Use" abbreviations in orders and medication-related documentation: U for unit, IU, QD and QOD, trailing zeros (X.0 mg), missing leading zeros (.X mg), and MS, MSO4 or MgSO4. See the Joint Commission "Do Not Use" list and use only your facility's approved abbreviations.
Don't record blame, staffing complaints or incident reports in the note. Document the facts of the event and the care given; file the incident report separately according to policy.

Where MentalNote fits

MentalNote drafts a note from a visit recorded in your browser with the patient's consent. For medical visits it uses one general Medical SOAP format (Chief Complaint, History of Present Illness, Review of Systems, Objective, and a numbered Assessment and Plan), and it is instructed to write "Not documented." for anything the visit did not cover. It has no nursing-specific templates such as SOAPIE, DAR or PIE, no flowsheets and no EHR write-back: you copy or export the reviewed note into your record. It suits visit-based work, such as nurse practitioners, clinic and telehealth visits, and psychiatric nurse practitioners. You check, edit and sign every note.

MentalNote is HIPAA-compliant, with a BAA included on every plan. The free plan includes 5 web-app scribe sessions a month with no credit card; Premium is $99/month or $990/year (pricing). You can open a fictional medical visit in the editor without signing up.

Sources

American Nurses Association. Principles for Nursing Documentation: Guidance for Registered Nurses (2010). nursingworld.org.
The Joint Commission. Official "Do Not Use" List (abbreviations, acronyms and symbols). jointcommission.org.
Pasero C. Assessment of sedation during opioid administration for pain management. Journal of PeriAnesthesia Nursing, 2009 (Pasero Opioid-induced Sedation Scale).

FAQ

Nursing notes: common questions

What is a nursing note?

A nursing note (also called a nurse's note or nursing progress note) is the nurse's entry in the patient record describing the patient's condition, the nursing care given and the patient's response. It supports continuity of care between shifts and disciplines and is part of the legal medical record. Many facilities record routine findings on flowsheets and use notes for changes, events, interventions and responses.

How do you write a nursing note?

Write it during care or as soon as possible afterwards. Record the date and time, your assessment findings (measured values and what you observed), the patient's own words in quotes, what you did, who you notified and what they said, and how the patient responded when you reassessed. Use objective, specific language and only approved abbreviations, and sign with your name and credentials as your facility requires.

What is the difference between SOAPIE and DAR charting?

SOAPIE is problem-oriented: Subjective, Objective, Assessment, Plan, Intervention and Evaluation. DAR is focus charting: you name a focus (a problem, concern, event or change in condition), then record Data (subjective and objective), Action (what you did) and Response (how the patient responded). Both record the intervention and the response; DAR is usually shorter.

What is PIE charting?

PIE stands for Problem, Intervention and Evaluation. It was developed as a nursing charting system. Assessment findings are recorded on a separate flowsheet, each problem is numbered (for example P1), and later entries refer to the problem by number, recording the intervention and its evaluation.

What is charting by exception?

Charting by exception means documenting only findings that differ from defined normal standards, usually on flowsheets. It saves time, but it relies on clear written standards in facility policy, and if an abnormal finding is not charted there is no record that it was assessed.

How do you write a late entry in nursing notes?

Label it as a late entry, record the current date and time when you write it, state the date and time the entry refers to, and write only what you remember accurately. Follow your facility's policy, which may limit how late an entry can be made. Never backdate an entry or change an earlier one to look as if it was written on time.

What should you not write in nursing notes?

Avoid opinions and labels such as "uncooperative" or "drug-seeking" (describe the behavior instead), vague phrases such as "had a good day" or "tolerated well" without specifics, blame of colleagues, staffing complaints, mentions of incident reports, and abbreviations on the Joint Commission "Do Not Use" list. Do not chart care before it is given or care given by someone else.

Can MentalNote write nursing notes?

MentalNote drafts notes from a visit recorded in your browser with the patient's consent. For medical visits it uses one general Medical SOAP format; it has no nursing-specific templates such as SOAPIE, DAR or PIE, no flowsheets and no EHR write-back. It suits nurses and nurse practitioners who document visit-based care, such as clinic, telehealth or outpatient behavioral health visits. You review, edit and sign every note. MentalNote is HIPAA-compliant, with a BAA included on every plan; the free plan includes 5 web-app scribe sessions a month, and Premium is $99/month or $990/year.

Record the visit. Review the draft. Sign it.

Open a fictional medical visit and edit a prepared Medical SOAP note. When you're ready, sign up free: 5 web-app scribe sessions a month, no credit card. Premium is $99/month or $990/year.

Try the medical sample, no signup