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How to Write Nursing Notes (With 10+ Examples): SOAP, DAR, Narrative

Nursing

Nursing notes might not sound exciting, but they’re one of the most powerful tools you have. They capture your observations, the actions you took, and the patient’s response — all in real time. Good notes don’t just keep your shift running smoothly; they also give you a clear record to stand on if care is ever reviewed.

If you’ve ever wondered how to write nursing notes examples that are simple, professional, and reliable, this guide will walk you through it. You’ll learn the difference between charting and notes, what to include in every entry, the main formats (SOAP, DAR, Narrative), and see real-world examples you can use right away.

In this article:

  • Nursing Notes vs. Charting
  • Nursing Note Formats (SOAP, DAR, Narrative)
  • How to Write Nursing Notes Step by Step
  • Nursing Note Examples (SOAPIE and DAR)
  • General Advice on Documentation
  • References

Nursing Notes vs. Charting

The terms “nursing notes” and “charting” often get mixed up, but they are not the same.

Charting is the big picture. It includes everything nurses must document: vital signs, medications, lab results, assessments, and interventions.

Nursing notes are your narrative entries inside that bigger record. They explain the “why” behind the data. Notes capture your decisions, actions, and the patient’s response in real time.

Here’s a simple way to see the difference:

  • Charting = the whole book.
  • Nursing notes = the chapters you write in your own words.

Both matter. Charting meets the legal and institutional requirements, while nursing notes add context that makes raw numbers meaningful. They connect the dots and make sure care is continuous and safe.

Nursing Note Formats

Different facilities may set their own templates, but three formats dominate nursing practice: Narrative, SOAP (or SOAPIE), and DAR. Each has its strengths. The key is knowing which one fits your situation best.

Narrative Notes

This is the oldest and most flexible format. You document events in chronological order, describing the patient’s condition, what you did, and how they responded.

When to use it: Home health, long-term care, or whenever you need context and flow.
Watch out for: Notes that become too long or wander into irrelevant details.

Example – Narrative Nursing Note
 09:45 Patient resting in bed. Reports mild headache, “throbbing, 4/10.” BP 128/82, HR 76, O₂ sat 96% RA. Administered Tylenol 500 mg PO as ordered. At 10:15 patient reports pain improved to 1/10.

SOAP Notes

SOAP provides structure. It stands for Subjective, Objective, Assessment, Plan. In nursing, it is often expanded to SOAPIE with Intervention and Evaluation. This format is especially useful in acute care or complex cases where clear reasoning is needed.

  • S: What the patient says (“My chest feels tight.”)
  • O: What you observe (vitals, assessment findings).
  • A: Your interpretation (for example, possible asthma flare, post-op pain).
  • P: What you plan to do (give medication, notify provider).
  • I: What you actually did.
  • E: The patient’s response.

When to use it: Hospitals, surgical units, or high-acuity care.
Watch out for: Making assumptions in the Assessment section without enough objective data.

Example – SOAPIE Note
 S: Patient reports shortness of breath, states “I can’t catch my breath.”
O: RR 28, O₂ sat 89% RA, accessory muscle use noted.
A: Likely acute asthma flare.
P: Administer albuterol nebulizer, notify provider.
I: Gave albuterol via nebulizer at 14:10.
E: O₂ sat improved to 95%, RR down to 20, patient states breathing is easier.

DAR Notes

DAR is concise but still covers essentials.

  • D (Data): Subjective and objective details.
  • A (Action): What you did.
  • R (Response): How the patient responded.

When to use it: Quick encounters, focused assessments, or documenting a single issue.
Watch out for: Oversimplifying complex care situations.

Example – DAR Note
 D: Patient reports nausea, “feeling queasy.” Vomited 200 ml clear fluid.
A: Administered Ondansetron 4 mg IV as ordered.
R: Nausea relieved after 20 minutes, patient resting comfortably.

How to Choose the Right Format

If you are still unsure which to use, here is a simple rule of thumb:

  • Narrative → When context and flow matter (home health, long-term care).
  • SOAP or SOAPIE → When structure helps clarify reasoning (acute care, post-op, emergencies).
  • DAR → When speed and focus matter (ED, urgent issues, or single-symptom care).

Some facilities mandate one format, so always check policy first. But if you have the flexibility, choose the format that makes your patient’s story easiest for the next provider to follow.

How to Write Good Nursing Notes (Step-by-Step)

Writing strong nursing notes doesn’t have to feel overwhelming. Think of it like following a recipe: gather the right ingredients, put them in order, and serve a clear picture for the next nurse or provider. Below is a step-by-step process you can use in any setting.

1. Start with the Basics

Every note begins with the date, time, and patient identifiers. This anchors the entry in the chart and prevents mix-ups. On paper charts, use black or blue ink only, since these colors hold up best legally. In electronic systems, double-check you’re in the right chart before you start typing—everyone has accidentally clicked into the wrong patient before.

Example: 09/21/25, 14:05 — John Smith, MRN 123456

2. Capture Subjective Data

Subjective data is what the patient or family tells you in their own words. Write it inside quotation marks and avoid interpreting or summarizing. Recording exact words protects you and makes the record clearer. It’s better to write “I feel dizzy when I stand up” than “patient dizzy.” The first shows the patient’s perspective; the second is an assumption.

Example: “My stomach feels tight, like it’s twisting.”
Example: Daughter states patient hasn’t eaten since breakfast.

3. Record Objective Data

Objective data is what you observe, measure, or assess. It could be vital signs, wound appearance, or auscultation findings. Write it in precise, measurable terms. Avoid vague language like “looks better” and use specific details instead. This helps the next nurse or provider picture the patient’s exact status.

Example: RR 22, O₂ sat 93% RA, faint expiratory wheeze on auscultation.

4. Note Your Actions

This is where you describe what you did in response to the situation. Actions can include giving medications, applying oxygen, changing dressings, repositioning, or teaching the patient. Always include the dose, route, and time for medications, and be clear about any education provided.

Example: Administered acetaminophen 500 mg PO at 10:00 per MAR order.
Example: Repositioned patient to right side and provided pillow support for comfort.

5. Document Patient Response

A good note closes the loop by showing how the patient responded to your actions. Did their pain lessen? Did their breathing improve? Or did nothing change? Documenting both positive and negative responses demonstrates that you are monitoring and reassessing appropriately.

Example: Patient reports pain improved from 6/10 to 2/10 after 30 minutes.
Example: O₂ sat increased to 96% with nasal cannula at 2 L/min.

6. Include Communication

If you contacted a provider or consulted another healthcare professional, always document the name and title of the person, along with the time. This shows that you escalated concerns and followed the chain of care. It also provides legal protection if there are questions later.

Example: Dr. Lee notified of patient’s chest pain at 11:20, awaiting new orders.
Example: Respiratory therapist John Brown at bedside to initiate nebulizer.

7. Close With Your Signature

End each note with your name and designation (or initials if the electronic system automatically records your credentials). This verifies who wrote the note and makes the entry valid. Never leave a note unsigned.

Example: Jane Doe, RN

Good Nursing Note Examples

Examples are the best way to see how nursing note formats work in practice. Below are concise, realistic samples written exactly as you would document them.

Post-Operative Pain SOAPIE Note Example

Patient: John Smith
Date: September 21, 2025

14:10: Patient reports pain at incision site, rating it 8/10 and describing it as “sharp and constant.” Dressing intact with a small amount of serosanguinous drainage noted. Vitals: BP 122/78, HR 92, SpO₂ 95% RA. (Subjective/Objective) Patient experiencing post-operative pain related to recent hernia repair. (Analysis) Plan is to reinforce education on PCA use and administer pain control as ordered. (Plan)

14:20: Writer reviewed PCA use with patient, emphasizing the importance of pressing the button at the first sign of pain. Patient verbalized understanding and demonstrated correct use. (Intervention)

14:50: Reassessed patient pain. Patient reports pain now 3/10, describes as “manageable.” Resting comfortably in bed with vital signs stable. (Evaluation)

Asthma Exacerbation DAR Note Example

Patient: Maria Lopez
Date: September 21, 2025

09:35: On assessment patient c/o shortness of breath, stating “It feels tight when I breathe.” Patient respiration rate 26, SpO₂ 90% on room air, expiratory wheeze audible bilaterally. (Data) Writer administered albuterol 2.5 mg via nebulizer per PRN order. (Action) At reassessment 15 minutes later, patient reported “breathing easier now.” Respiratory rate decreased to 18, SpO₂ improved to 96% RA, wheeze reduced on auscultation. (Response)

Post-Op Shift Narrative Nursing Note Example

09:15: Patient resting in bed following laparoscopic cholecystectomy. Reports abdominal discomfort, “aching, 5/10.” Dressing clean, dry, and intact with no drainage observed. Vitals stable: BP 120/80, HR 84, RR 18, SpO₂ 96% RA. Assisted patient to sit up at edge of bed; tolerated well. Encouraged use of incentive spirometer, which patient performed ×10 with good technique. Provided education on importance of deep breathing and coughing to prevent pneumonia. Patient verbalized understanding. Will continue to monitor pain and encourage mobility.

Wound Care SOAPIE Note Example

Patient: Jill Doe
Date: September 21, 2025

11:00: Patient states, “It stings when you touch the wound.” (Subjective) Stage II pressure ulcer on sacrum, 1.5 cm in diameter, no drainage, surrounding skin intact. Vitals stable. (Objective) Pressure ulcer requiring dressing change. (Analysis) Plan to cleanse wound and apply hydrocolloid dressing. (Plan)

11:10: Wound cleansed with normal saline and new hydrocolloid dressing applied. Patient repositioned to right side with pillows for support. (Intervention)

11:40: On reassessment, patient reports pain now 2/10, tolerating position well. Dressing intact with no bleeding noted. Patient resting comfortably in bed. (Evaluation)

Nausea DAR Note Example

Patient: Robert Taylor
Date: September 21, 2025

15:05: Patient complained of nausea, stating “I feel like I might throw up.” One episode of emesis measured at 150 ml of clear fluid. Vitals: HR 88, BP 118/74. (Data) Writer administered ondansetron 4 mg IV as ordered. (Action) At reassessment 20 minutes later, patient reported nausea relieved, no further vomiting noted, resting quietly in bed. (Response)

Pediatric Dehydration SOAPIE Note Example

Patient: Emily Johnson, 4 years old
Date: September 21, 2025

08:20: Mother reports child “hasn’t urinated since yesterday.” Child appears tired, lips dry, cap refill 3 seconds. HR 118, BP 90/60, Temp 99.1°F, mucous membranes dry. (Subjective/Objective) Likely mild dehydration related to gastroenteritis. (Analysis) Plan to initiate IV fluids and educate mother on oral rehydration strategies. (Plan)

08:35: IV NS started at 50 ml/hr, explained hydration importance to mother, demonstrated oral rehydration solution preparation. Mother verbalized understanding. (Intervention)

09:10: Child more alert, lips moist, cap refill <2 seconds. HR 104, BP 96/64. Mother demonstrates correct use of ORS and states confidence in continuing at home. (Evaluation)

Mental Health (Anxiety Episode) DAR Note Example

Patient: Daniel Wright
Date: September 21, 2025

19:15: Patient pacing room, stating “I feel like something bad is going to happen.” HR 110, RR 24, fidgeting, appearing restless. (Data) Writer provided reassurance, guided patient through 5-minute breathing exercise, and encouraged grounding techniques. (Action) At 19:40, patient reported “I feel calmer now,” HR 88, RR 18, sitting quietly at table engaged in coloring activity. (Response)

Home Health Visit Narrative Nursing Note Example

14:30: Arrived at patient’s home for routine diabetic foot care. Patient reports, “My foot feels sore when I walk.” Inspection revealed a small blister on right heel, approximately 0.5 cm, intact skin, no drainage, surrounding skin slightly reddened. Vitals within normal limits. Cleansed area with NS, applied protective dressing, and educated patient on importance of daily foot checks and wearing well-fitting shoes. Patient’s spouse present during teaching and demonstrated understanding of wound care instructions. Patient ambulated short distance in home with steady gait, no complaints of dizziness. Will reassess blister at next visit and advise patient to contact clinic if redness or drainage increases.

Emergency (Fall Injury) SOAPIE Example

Patient: William Harris
Date: September 21, 2025

16:05: Patient brought in after fall at home. Reports left hip pain 9/10, describes as “sharp, worse with movement.” Leg externally rotated, shortened. Vitals: BP 138/82, HR 102, SpO₂ 94% RA. (Subjective/Objective) Suspected left hip fracture. (Analysis) Plan to administer analgesia and prepare for X-ray as ordered. (Plan)

16:15: Administered morphine 4 mg IV for pain relief, applied cold pack to left hip, maintained immobilization, and notified orthopedic team. (Intervention)

16:45: Patient reports pain decreased to 5/10, lying still with cold pack in place. Awaiting X-ray. Orthopedic resident informed and en route. (Evaluation)

Geriatric (Orthostatic Hypotension) DAR Example

Patient: Margaret Lewis, 78 years old
Date: September 21, 2025

10:05: During morning assessment, patient reported dizziness upon standing. BP sitting 128/76, standing 100/64, HR 96. (Data) Writer assisted patient back to seated position, encouraged slow positional changes, and provided education on rising gradually from bed. (Action) At reassessment 15 minutes later, patient denied further dizziness, BP 122/74 sitting, tolerated standing with minimal unsteadiness. (Response)

General Advice on Writing Good Nursing Notes

High-quality nursing notes are as important as the care you deliver. They are not just paperwork; they protect your license, ensure safe care, and keep the whole team aligned. Here are some tips to guide your documentation:

  • Be timely. Chart as soon as possible after providing care. Delays increase the chance of missing or forgetting details, and late entries may look inaccurate.
  • Be objective. Write what you see and hear, not what you assume. For example, use “Patient pacing room, states ‘I feel anxious’” instead of “Patient anxious.”
  • Use both subjective and objective data. Patient quotes combined with your clinical findings give the most complete picture.
  • Limit abbreviations. Stick to those approved by your facility. Unapproved or banned abbreviations can cause confusion or create legal risk.
  • Correct mistakes properly. Never erase or delete an entry. For paper charts, draw a single line through the error and add your initials. In electronic systems, follow your facility’s protocol.
  • Check for continuity. Before finishing, ask: Could another nurse safely take over this patient’s care using only my note? If not, add more detail.
  • Keep it legible. For paper notes, always use black or blue ink. For EMRs, make sure formatting is clear and concise.
  • Think of each note as a handoff. Even if you’re not leaving shift yet, your documentation becomes part of the permanent story of your patient’s care.

References

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