Introduction to Mental Health Nursing Notes

What Are Mental Health Nursing Notes?

Mental health nursing notes are structured records that document a patient’s emotional, cognitive, and behavioral status. These notes capture everything from patient observations to nursing interventions and the patient’s response, offering a comprehensive picture of their mental health.

Why Mental Health Nursing Notes Matter

• Clear Communication: They provide a way for the healthcare team to share important information and ensure continuity of care.
  
• Patient Safety: They help track potential safety risks, such as suicidal ideation or aggression, and make it easier to address these risks promptly.
  
• Legal Protection: Proper documentation helps protect both the patient and the nurse in case of any legal inquiries or disputes, especially in high-risk situations.
  

Essential Principles for Writing Mental Health Nursing Notes

Objectivity in Documentation

When writing mental health nursing notes, it’s crucial to stick to the facts. Document only what you can see, hear, or measure, without adding personal opinions or emotional reactions.

• Example: Instead of writing “The patient seems anxious,” describe what you observed: “The patient paced the room for 15 minutes, wringing their hands and avoiding eye contact.”
  

Clarity and Accuracy

Good documentation should be clear and specific. The more precise you are, the easier it is for others to understand the patient’s condition and what actions were taken.

• Use exact durations: For example, “The patient was crying for 10 minutes” is more useful than simply “The patient was upset.”
  
• Include direct quotes when necessary, especially if the patient shares something important related to their mental state or safety.
  

Non-Judgmental, Behavior-Based Language

Avoid using subjective labels like “manipulative,” “attention-seeking,” or “dramatic.” Instead, focus on documenting behavior and the impact it has on the situation.

• Example: Instead of writing “The patient is manipulative,” write, “The patient requested medication multiple times in 10 minutes.”
  
• This keeps your documentation objective and ensures it remains legally sound.
  

How to Write Mental Health Nursing Notes: Step-by-Step Process

Step 1: Document the Patient’s Subjective Statements

Start by writing down exactly what the patient says. These statements provide insight into their emotional state and concerns. Whenever possible, use direct quotes to capture their feelings and thoughts.

• Example:
  
  • Subjective: “I feel like I’m losing control. I can’t stop crying.”
    

Step 2: Document Objective Observations

Next, note what you observe about the patient’s behavior, appearance, and physical state. This includes things like body language, speech patterns, and mood. Be specific and avoid vague terms.

• Example:
  
  • Objective: “The patient paced for 15 minutes, wringing their hands and avoiding eye contact.”
    

Step 3: Provide Your Clinical Assessment

Offer your clinical interpretation based on the subjective and objective data. This is where you assess how the patient’s behavior or symptoms may indicate a particular condition or change in their mental state.

• Example:
  
  • Assessment: “Patient shows signs of anxiety and restlessness, likely due to increasing depressive symptoms.”
    

Step 4: Document the Plan of Care or Next Steps

Outline what you plan to do next. This could include interventions, medication administration, or other actions to address the patient’s needs.

• Example:
  
  • Plan: “Encouraged the patient to practice deep breathing exercises. Will continue to monitor for panic attacks and provide support.”
    

Step 5: Record Interventions and the Patient’s Response (if applicable)

If any interventions were performed, document what you did and how the patient responded. Be specific about timing and the patient’s reaction.

• Example:
  
  • Intervention/Evaluation: “Administered PRN lorazepam. Patient reported feeling calmer after 20 minutes and appeared more relaxed.”
    

Common Documentation Formats for Mental Health Nursing Notes

SOAP / SOAPIE Notes

SOAP is one of the most commonly used formats for organizing mental health nursing notes. It ensures that all necessary details are documented in a clear and structured way.

• S – Subjective: Write exactly what the patient says about their condition.
  
  • Example: “I feel like I’m trapped. I can’t think clearly anymore.”
    
• O – Objective: Note your observations, such as behaviors or physical signs.
  
  • Example: “Patient appears disheveled, with poor hygiene. Speech is slow and monotone.”
    
• A – Assessment: Your clinical interpretation based on the subjective and objective data.
  
  • Example: “The patient is exhibiting symptoms of depression with cognitive impairment.”
    
• P – Plan: Document what steps will be taken to address the patient’s condition.
  
  • Example: “Encouraged participation in group therapy. Will continue monitoring mood and assess for suicidal ideation.”
    
• I/E (optional) – Intervention/Evaluation: Record the actions you took and the patient’s response to those actions.
  
  • Example: “Administered PRN antidepressant. Patient reports feeling slightly better after 30 minutes.”
    

When to Use SOAP:

• Ideal for documenting therapy sessions, symptom tracking, or suicidal ideation.
  

DAP / DAR Notes

DAP and DAR notes are more concise formats, perfect for documenting specific behaviors or incidents.

• D – Data: Record the key information you observe.
  
  • Example: “Patient is pacing the room, appearing anxious and tense.”
    
• A – Action: Document the intervention or action you took.
  
  • Example: “Guided patient to a quieter space and initiated relaxation exercises.”
    
• R – Response: How did the patient react to the intervention?
  
  • Example: “Patient appeared calmer after 15 minutes, with slower breathing.”
    
• P/R – Plan or Response: Outline the next steps or follow-up actions.
  
  • Example: “Will continue to monitor, encourage coping strategies, and assess for signs of escalating anxiety.”
    

When to Use DAP/DAR:

• Great for agitation, medication refusals, or short-term behavior updates.
  

BIRP Notes

BIRP notes are especially useful in inpatient settings where you need to document behavioral interventions and their effectiveness.

• B – Behavior: Describe the patient’s actions or behavior.
  
  • Example: “Patient was observed pacing, speaking loudly and interrupting peers.”
    
• I – Intervention: What actions did you take?
  
  • Example: “Redirected patient to a quiet area, set clear boundaries, and provided coping strategies.”
    
• R – Response: How did the patient respond to your intervention?
  
  • Example: “Patient calmed down after 20 minutes and began to engage in a less intrusive manner.”
    
• P – Plan: Document the next steps.
  
  • Example: “Continue to monitor behavior, encourage participation in low-stimulation activities.”
    

When to Use BIRP:

• Useful during behavioral crises, agitation, or medication administration during inpatient care.

Narrative Notes

Narrative notes offer flexibility when documenting complex or evolving situations. They are particularly useful when there is a need for a clear, chronological account of events, especially when multiple staff members intervene or when the situation involves sudden changes.

When to Use Narrative Notes:

• Restraints or seclusion — Documenting incidents that require physical intervention.
  
• Elopement attempts — If the patient attempts to leave the unit without permission.
  
• Flashbacks, panic attacks, or dissociation — When patients experience acute distress or lose touch with reality.
  
• Multiple staff interventions — When more than one staff member is involved in responding to the patient’s needs or behaviors.
  
• Safety documentation — When documenting ongoing safety concerns, especially in a rapidly changing environment.

Read more on Good nursing Notes

When to Use Each Format (Quick Table)

Each format has its strengths. With practice, you’ll start recognizing which one fits the moment without even thinking about it.

Mental Health Nursing Notes Example (SOAP)

• Subjective:
  “Nothing matters anymore. I feel exhausted and empty. I don’t want to be here.”
  (Patient expresses feelings of hopelessness and lack of energy.)
  
• Objective:
  “Patient appears tearful, with a flat affect. Stayed in bed most of the shift. Ate only 25% of lunch. Poor eye contact during interactions.”
  (Documenting observable behaviors and physical signs like poor eating and lack of eye contact.)
  
• Assessment:
  “Worsening depressive symptoms with passive suicidal ideation (SI), as indicated by patient’s statement about not wanting to be here. Low immediate risk due to lack of a plan or intent.”
  (The nurse interprets the patient’s state, considering the possibility of passive SI but assessing a lower risk due to the absence of a clear plan.)
  
• Plan:
  “Encouraged participation in group therapy; reinforced coping strategies; will continue to monitor for changes in mood and safety. Will update the provider.”
  (The plan focuses on therapeutic interventions and safety monitoring.)

Mental Health Nursing Notes Example (DAR) 

• Data:
  “Patient reports feeling like they can’t breathe. HR 120, trembling, hyperventilating, and unable to remain seated. Appears visibly distressed and avoids eye contact.”
  (Documenting the patient’s subjective feelings and physical symptoms, including vital signs and observable behaviors.)
  
• Action:
  “Guided patient through paced breathing exercises. Encouraged slow inhalations and exhalations, and provided reassurance. Administered PRN hydroxyzine as per provider’s orders.”
  (The nurse intervenes by guiding the patient through a calming exercise and administering medication.)
  
• Response:
  “Patient appeared calmer after 10 minutes. HR decreased to 95, trembling subsided, and breathing normalized. Patient reported feeling ‘a little better’ but continued to feel uneasy.”
  (The nurse documents the effectiveness of the intervention and the patient’s response.)
  
• Plan:
  “Continue monitoring patient for further signs of anxiety. Offer additional coping techniques, such as grounding exercises. Will reassess in 30 minutes.”
  (The plan includes follow-up monitoring and additional interventions if needed.)

Mental Health Nursing Notes Example (BIRP) 

• Behavior:
  “Patient pacing around the room, speaking in a loud, pressured manner. Stated, ‘The voices are telling me to hide, they’re going to get me.’ Appears visibly distressed, eyes darting around the room, avoiding staff.”
  (Documenting the patient’s behavior, speech, and signs of agitation and paranoia.)
  
• Intervention:
  “Redirected patient to a quiet room for safety. Provided reassurance, using calm and clear communication. Administered PRN risperidone as ordered by the provider.”
  (The nurse takes action to redirect the patient to a safer space and offers medication to help manage symptoms.)
  
• Response:
  “Patient calmed down after 20 minutes. Voices reported as ‘softer.’ Patient able to sit quietly, with improved eye contact and less agitation.”
  (Documenting the effectiveness of the intervention and the patient’s response to medication.)
  
• Plan:
  “Continue to monitor patient for further hallucinations and agitation. Encourage participation in group therapy. Will notify provider if symptoms persist or escalate.”
  (The plan outlines ongoing monitoring and a referral for additional care if needed.)
  

Mental Health Nursing Notes Example (Narrative Note)

“Patient was observed pacing near the exit door at 1410, repeatedly stating, ‘Someone is coming for me.’ Breathing rapid, eyes wide, scanning hallway. Attempted to leave unit; redirected by staff. Provided reassurance and guided patient to quiet room. Patient initially resistant but eventually sat with encouragement. At 1420, patient stated, ‘I hear footsteps behind me.’ No one present. Administered PRN lorazepam 1 mg for anxiety. Patient calmer within 20 minutes, now sitting in lounge watching TV. Denies intent to harm self or others. Continues on q15-minute safety checks.”

Common Mistakes to Avoid When Writing Mental Health Nursing Notes

1. Using Judgmental Language

It’s easy to slip into using labels that reflect frustration or personal opinions, but this can compromise the objectivity of your notes. Words like “manipulative,” “attention-seeking,” or “dramatic” don’t describe behavior; they describe feelings.

• Better Approach: Focus on the behavior itself and how it impacts care.
  
  • Example: Instead of “The patient is manipulative,” write, “The patient requested medication multiple times in a short period.”
    

2. Overusing Abbreviations

While it’s tempting to use abbreviations for speed, it’s essential to only use approved facility abbreviations. Overuse can lead to confusion or misinterpretation of critical information.

• Better Approach: If you’re unsure about an abbreviation, write the full term to avoid ambiguity.
  
  • Example: Instead of “Pt. has SI,” write “Patient has suicidal ideation.”
    

3. Incomplete Documentation

Leaving out crucial details, such as patient responses or safety concerns, can lead to gaps in care or important information being missed.

• Better Approach: Ensure all aspects of care are documented, including patient statements, interventions, and responses.
  
  • Example: Always document actions taken when safety is a concern: “Patient was placed on 1:1 observation due to verbal threats.”
    

4. Writing Vague or General Notes

Vague notes don’t provide a complete picture. Instead of saying “The patient seemed upset,” document what you observed and the patient’s behavior in specific terms.

• Better Approach: Be specific about what you saw, heard, or measured.
  
  • Example: Instead of “The patient seemed upset,” write, “The patient was pacing, wringing hands, and speaking rapidly with a tense posture.”
    

5. Failing to Update Notes After Changes

Mental health status can change rapidly, and your notes should reflect these changes. If a patient’s condition shifts, especially with safety concerns, make sure to update the documentation immediately.

• Better Approach: Regularly review and update notes to reflect any changes in behavior, mental state, or interventions.
  
  • Example: If a patient who was previously calm starts showing signs of agitation, update the note to reflect the change and any new interventions.

Conclusion

Writing effective mental health nursing notes is essential for clear communication, patient safety, and legal protection. By focusing on behavioral observations, objective language, and accurate documentation, you can create notes that not only track patient progress but also ensure that care is delivered safely and professionally.

• Remember the Key Principles: Objectivity, clarity, and non-judgmental language are crucial in writing accurate and helpful notes.
  
• Use the Right Format: Choose the appropriate documentation format (SOAP, DAP, BIRP, or Narrative) based on the patient’s needs and the situation at hand.
  
• Learn from Examples: Always refer to real-world examples of mental health nursing notes to guide your practice. With time and consistent practice, documenting mental health care will become second nature.
  

As a student or new grad, don’t be discouraged by the learning curve. The more you practice writing notes and reviewing examples, the more confident you’ll become in your documentation skills. Strong mental health nursing notes ensure better care — for you, your team, and most importantly, your patients.