Nursing Notes & Documentation Examples
Nursing documentation is the written record of assessments, care and the patient's response. Clear documentation lets the whole team see what happened and what needs to happen next.
Formats such as narrative, DAR, SOAP, SOAPIE and SBAR organize the same core ideas differently. Pick the guide that matches the format your program or facility uses. Actual documentation requirements depend on your employer or facility policy, EHR design, role, setting and applicable law or regulation.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyNote formats
- Narrative notesA narrative note is a chronological written account of assessments, care and the patient's response, written in complete sentences rather than in labelled sections..
- DAR notesDAR is a focus-charting format that organizes an entry around a specific concern using three parts: Data, Action and Response..
- SOAP notesSOAP is a problem-oriented format with four parts: Subjective, Objective, Assessment and Plan..
- SOAPIE notesSOAPIE extends SOAP with two more parts: Intervention (what was done) and Evaluation (how the patient responded)..
- SBARSBAR (Situation, Background, Assessment, Recommendation) is a structured way to communicate important information about a patient, most often during a phone call, a handoff or an escalation of a concern..
- Charting by exceptionCharting by exception (CBE) is a documentation approach in which the organization and its documentation system define expected findings in advance, and findings that differ from those defined standards are documented in detail.
- Progress notesA progress note is an entry that records the patient's status, care and response over a period of time.
Clinical documentation examples
Original fictional examples. They are not mandatory forms, and copying one does not make documentation compliant.
- Head-to-toe assessmentHead-to-toe assessment documentation records the findings of a systematic physical assessment, usually organized by body system..
- Admission noteAn admission nursing note documents a patient's arrival and the baseline nursing assessment and orientation completed at admission..
- End-of-shift noteA shift or end-of-shift note summarizes the patient's status, key events, care and responses during a shift..
- Change in conditionA change-in-condition note documents a significant change in a patient's status and the nursing actions and communication that followed..
- Provider notificationA provider notification note documents that a nurse communicated information to a provider, what was communicated, and the response..
- Patient educationA patient education note documents what was taught, how, to whom, and how learning was actually evaluated..
- Pain & reassessmentA pain note documents the patient's reported pain, the interventions performed, and the reassessment that follows..
- Fall / post-fallA post-fall note documents the facts of a fall in the clinical record: what was observed or known, assessment findings, actions performed, notifications made and follow-up..
- Wound assessmentWound documentation describes a wound's location, size, appearance, drainage and surrounding skin, and records the care actually performed..
- Medication responseA medication response note documents why a medication was given (especially PRN), and the patient's response on reassessment.
- IV site assessmentIV site documentation records the device, location, appearance of the site, patency and any infusion, at the intervals required by policy..
- Intake & outputIntake and output documentation records measured fluids taken in and fluids lost over a set period, usually on a flowsheet..
- Discharge noteA discharge note documents the patient's condition at discharge, the instructions reviewed, how understanding was evaluated, and how the patient left..
- Refusal of careA refusal note documents that a patient declined an offered care item, what they said, what information was provided, and who was informed..
- Transfer / handoffA transfer or handoff note documents that responsibility for a patient moved to another nurse, unit or facility, and the patient's status at that time..
Documentation skills
- Objective vs subjectiveTell reported information apart from observations.
- Documentation do's and don'tsGeneral principles: factual, timely, attributed.
- Good vs poor documentationSide-by-side fictional comparisons.
- Abbreviations & number safetyThe Joint Commission Do Not Use list.
- Blank templates15 printable prompt-only templates.
- Documentation practiceQuestions with instant explanations.
- Privacy & safetyWhy only fictional information belongs here.
Practice Note Builder
Choose one of 20 fictional scenarios, write a narrative, DAR, SOAP, SOAPIE or SBAR practice note, then compare with example documentation built only from the scenario's facts. Your text is never saved or sent.
Open the Practice Note Builder