For many nurses, the real challenge isn’t the care itself — it’s documenting that care in a clear and accurate way. Yet those notes carry as much weight as the intervention itself. Poorly written notes can leave gaps in care, confuse the team, or even create legal risk. Clear notes, on the other hand, tell the patient’s story from start to finish.
Still, many nurses feel uncertain when it comes to writing narrative notes. What should you include? How do you avoid being vague or repetitive? That’s where narrative nursing notes examples can help. This guide will show you what makes a good note, provide real-world examples, and share simple tips you can use right away.
In this article:
- What Are Narrative Nursing Notes?
- Narrative vs. Structured Documentation Formats
- How to Write Narrative Notes Step by Step
- Real-World Narrative Nursing Notes Examples
- Tips for Faster, Clearer Documentation
- FAQs
What Are Narrative Nursing Notes?
Narrative nursing notes are written in story form, recording care in a clear, chronological flow. Instead of relying on checkboxes, they let you describe what happened, when it happened, and how the patient responded.
Think of them as clinical storytelling. You’re not only listing symptoms or tasks — you’re showing the full picture of the patient’s condition, your interventions, and the outcomes. This makes narrative notes especially valuable when cases are complex, unusual, or when every detail matters for patient safety and legal protection.
Narrative Nursing Notes vs. Structured Documentation
The way you document care changes how the patient’s story is told. Nurses often use three main styles: narrative notes, SOAP notes, and charting by exception. Each has its strengths, but narrative notes give the most complete picture.
Narrative Notes (Clinical Storytelling)
These are written in full sentences, almost like telling a story. They’re flexible and let you include details that don’t fit into a checklist.
Example:
“1400 – Patient reports sharp pain at incision site, rating 8/10. Morphine 4mg IV given. At 1430, pain decreased to 4/10 and patient appeared more relaxed.”
SOAP Notes Nursing Examples (Structured Format)
SOAP stands for Subjective, Objective, Assessment, and Plan. This format is structured and easy to scan.
Example:
- S: “Pain 8/10 at incision”
- O: Grimacing, guarding, vitals stable
- A: Acute post-op pain
- P: Morphine 4mg IV given, reassess in 30 min
Charting by Exception (When Less Is Enough)
This is the most concise. You only document what’s unusual or abnormal.
Example:
“Pain: 8/10 → 4/10 post-medication. Morphine 4mg IV given per protocol.”
Choosing the Right Documentation Style
- SOAP notes are great for structure and speed.
- Charting by exception saves time when patients are stable.
- Narrative notes remain best for complex situations, legal clarity, and showing the patient’s full story.
Essential Components of Narrative Nursing Notes
For narrative notes to be complete and legally sound, they should include six key elements:
- Date and time – Always use 24-hour time for clarity.
- Patient identification – Room number or other identifiers.
- Subjective data – What the patient or family says (use direct quotes).
- Objective findings – What you observe or measure (vitals, behavior, labs).
- Interventions – What you did (medications, teaching, repositioning, safety).
- Response and evaluation – How the patient reacted and next steps.
These six parts ensure your note tells the whole story — not just what happened, but also how it was managed and how the patient responded.
How to Write Narrative Notes Step by Step
Writing effective narrative notes follows a clear process. Master these steps, and you’ll document faster while creating better notes.
Pre-Documentation Preparation
Before you write anything, gather your information systematically.
1: Review the patient’s current condition and history. What’s changed since your last assessment? Look for patterns and trends.
2: Identify key events from your shift. What were the most important things that happened? Focus on:
- Changes in patient condition
- Interventions performed
- Patient responses to treatment
- Provider communications
3: Organize events chronologically. Put events in time order. This creates a logical flow that’s easy to follow.
4: Gather specific data. Have exact times, vital signs, and measurements ready. Avoid guessing or approximating.
Step 1 – Record Time and Setting
Every narrative note begins with when and where events occurred.
Format: HHMM (24-hour time) – Setting/Unit
Examples:
- “1400 – Medical ICU, Room 302”
- “0630 – Emergency Department, Triage Area”
Step 2: Document Subjective Information
Subjective data comes directly from the patient or family. Always use quotation marks for direct quotes.
What to include:
- Patient’s exact words about symptoms
- Family concerns or observations
- Patient’s questions or fears
- Emotional responses
Examples of effective subjective documentation:
Pain reporting:
- Patient states “The pain is like a knife stabbing me in my side, about an 8 out of 10”
Emotional concerns:
- Patient asks “Will I be able to walk normally after this surgery?”
Family input:
- Daughter reports “Mom hasn’t been eating well for three days and seems confused”
Step 3: Record Objective Observations
Objective data is what you can see, hear, feel, or measure. This section requires precision.
Physical assessment findings include:
- Vital signs with exact numbers
- Physical appearance and behavior
- Body system assessments
- Laboratory values
Examples:
- “Patient grimacing, clutching abdomen, lying in fetal position”
- “Surgical incision 15cm, edges approximated, no redness or swelling noted”
- “BP 120/75, HR 78, RR 16, Temp 98.6°F”
- “150ml serosanguineous drainage from JP drain”
Step 4: Describe Interventions and Actions
Document every nursing intervention you performed. This section protects you legally and guides other nurses.
What to include:
- Nursing interventions performed
- Medications administered (dose, route, time)
- Patient education provided
- Healthcare provider communications
- Safety measures implemented
Strong action verbs for documentation:
- Administered, assessed, applied, contacted
- Educated, elevated, encouraged, evaluated
- Monitored, notified, observed, positioned
- Provided, reassured, repositioned, supported
Step 5: Evaluate and Document Outcomes
The evaluation step completes the nursing process. Did your interventions work? How did the patient respond?
What to evaluate:
- Patient’s response to interventions
- Progress toward established goals
- Effectiveness of treatments
- Need for continued monitoring
Outcome measurement examples:
Successful intervention: “Following repositioning and pillow support, patient rates back pain as decreased from 7/10 to 3/10. Able to rest comfortably without further position changes needed.”
Partial success: “Patient demonstrated understanding of diabetic diet teaching by correctly identifying appropriate food choices. Requires reinforcement on portion control and carbohydrate counting.”
Real-World Narrative Nursing Notes Examples
Learning from actual examples makes the difference between good and great documentation. These examples come from real nursing situations across different specialties.
Each example includes the complete narrative note, analysis of what makes it effective, and key learning points you can apply immediately.
Example 1: Medical-Surgical – Post-Operative Pain (Narrative Note)
09/28/2025 – 1430
Patient is a 46-year-old female, post-op day 1 following abdominal hysterectomy, in Room 302. At 1430, patient stated, “I have sharp pain at my incision, about eight out of ten.” She was observed grimacing and holding her lower abdomen. Incision site clean, dry, and intact with no drainage noted. Vital signs at this time: BP 145/88, HR 98, RR 20, Temp 37.2°C, SpO₂ 97% on room air. Morphine 4mg IV was administered per order, and the patient was repositioned to semi-Fowler’s with pillow support. She was encouraged to take slow, deep breaths.
At 1500, patient reported her pain decreased to four out of ten, stating, “It feels much better, I can relax now.” She appeared comfortable, breathing unlabored, and vital signs remained stable. Will continue to monitor pain every two hours, reinforce use of call bell for breakthrough pain, and encourage early ambulation later today per protocol.
Example 2: ICU – Neurological Change (Narrative Note)
09/28/2025 – 1200
Patient is a 58-year-old male admitted with traumatic brain injury, currently in ICU bed 14. At 1200, neurological assessment revealed a decline in Glasgow Coma Scale from 15 at 0800 to 13 (E4, V4, M5). Patient was oriented to person and place but confused about date. Pupils measured at 3mm bilaterally, equal and reactive to light. He appeared increasingly restless and attempted to remove his oxygen cannula despite verbal redirection. ICP monitor reading was 18 mmHg, elevated from baseline 10–12.
Physician was notified immediately, and stat CT scan was ordered. Family was updated about the change in condition. Continuous neuro checks were initiated every 15 minutes. Patient remains on oxygen via nasal cannula at 2L/min. Safety measures reinforced, including padded side rails and close observation at bedside.
Example 3: Emergency Department – Trauma Admission (Narrative Note)
09/28/2025 – 2130
Patient is a 34-year-old male brought to the ED via ambulance following a motor vehicle accident. On arrival at 2130, patient was awake, alert, and oriented ×3. He reported severe left leg pain rated 9/10, stating, “It hurts too much, I can’t move it.” On examination, obvious deformity noted to left femur with swelling and bruising present. Pedal pulse palpable but weak. Vital signs: BP 132/84, HR 104, RR 22, SpO₂ 96% on room air. No other visible injuries at this time.
At 2140, a large-bore IV (18g) was established in right antecubital fossa. Normal saline started at 125 mL/hr. At 2145, morphine 4mg IV was administered as ordered for pain management. Patient reassessed at 2200; pain reduced to 6/10, and he stated, “It’s better, but still hurts.” Orthopedic consult requested, and X-ray of left femur ordered stat. Patient remains NPO, placed on continuous monitoring, and prepared for possible transfer to OR.
Example 4: Mental Health – Suicide Attempt (Narrative Note)
09/28/2025 – 0315
Patient is a 28-year-old female admitted to the psychiatric unit under a 72-hour hold following a reported overdose. She arrived to the ED at 0315 via ambulance after calling 911 herself. On admission, patient stated, “I took about 20 acetaminophen tablets, but then I got scared and called for help.” She was alert and cooperative, though appeared tearful. Denied current suicidal intent, saying, “I don’t want to die now.”
On assessment, vital signs stable: BP 118/76, HR 90, RR 18, Temp 36.8°C, SpO₂ 98% RA. Patient displayed flat affect but maintained appropriate eye contact. No evidence of hallucinations or delusions. Skin warm and dry, no injuries noted.
At 0330, activated charcoal administered per physician order. Continuous observation initiated, belongings secured, and suicide precautions put in place. Patient reassured regarding treatment process and informed about psychiatric evaluation. Family contacted; mother notified and confirmed en route.
Patient remains stable at this time. Will continue close monitoring, document behavioral changes, and await psychiatry consult for further management.
Example 5: Pediatrics – Asthma Exacerbation (Narrative Note)
09/28/2025 – 1045
Patient is a 5-year-old male who presented to the ED with increased work of breathing. Mother reported, “He has been wheezing since yesterday and it got worse this morning.” On arrival at 1045, child appeared anxious, sitting upright on mother’s lap, with audible wheezing. Respiratory rate 32, O₂ saturation 91% on room air. Accessory muscle use noted with mild nasal flaring. Skin warm, slightly flushed, no cyanosis observed.
At 1100, albuterol 2.5mg via nebulizer initiated as ordered. Child remained in upright position, tolerated treatment with mother present for reassurance. By 1110, respiratory rate decreased to 24, O₂ saturation improved to 96% on room air. Child verbalized, “I can breathe better now,” and appeared calmer.
Parents were educated about asthma triggers, importance of medication adherence, and when to seek emergency care. Discharge planning to include referral to outpatient pediatric pulmonology for follow-up.
Example 6: Obstetrics – Labor and Delivery
09/28/2025 – 0615
Patient is a 29-year-old G2P1 admitted in active labor at 39+2 weeks gestation. At 0615, patient reported contractions every 3–4 minutes, rating pain 7/10, stating, “It feels much stronger now.” On exam, cervix 6cm dilated, 90% effaced, vertex presentation at -1 station. Fetal heart tones 140 bpm with moderate variability, no decelerations noted.
At 0630, patient assisted to upright position with birthing ball for comfort. Breathing techniques reinforced and husband present for support. Epidural anesthesia requested; anesthesia team notified. Patient reassured and safety measures maintained.
Example 7: Geriatrics – Long-Term Care / Nursing Home
09/28/2025 – 0945
Patient is an 82-year-old female resident with history of dementia and hypertension. At 0945, patient observed ambulating without walker in hallway, appearing unsteady. When redirected, patient stated, “I was looking for my daughter.” No acute distress noted. Vital signs stable: BP 134/78, HR 82, RR 18, Temp 36.7°C, SpO₂ 97% RA.
Patient assisted back to room, oriented to surroundings, and provided reassurance. Fall-risk bracelet intact, bed alarm re-activated, and call bell placed within reach. Family notified of increased restlessness. Will continue to monitor safety and reinforce use of walker.
Example 8: Community / Home Health
09/28/2025 – 1430
Patient is a 63-year-old male with Type 2 diabetes seen at home for wound care follow-up. At 1430, patient stated, “My foot feels less sore this week.” On inspection, ulcer on right plantar surface measured 2cm × 1cm, edges pink, scant serosanguinous drainage, no odor. Surrounding skin intact with no erythema. Vital signs stable, blood glucose 146 mg/dL pre-meal.
Wound cleansed with saline, non-adherent dressing applied, and patient educated on daily foot checks and importance of offloading pressure. Wife present during visit, verbalized understanding of care instructions. Patient tolerated procedure well. Will return in 48 hours for reassessment.
Example 9: Oncology – Chemotherapy Infusion
09/28/2025 – 1015
Patient is a 56-year-old female with Stage II breast cancer admitted to oncology unit for Cycle 2, Day 1 of adjuvant chemotherapy. At 1015, patient arrived ambulatory with husband, reporting mild fatigue but no nausea. Stated, “I’ve been feeling a little more tired this week, but otherwise okay.” Vital signs stable: BP 122/80, HR 88, RR 18, Temp 36.9°C, SpO₂ 99% RA. Peripheral IV line established in left forearm with brisk blood return.
At 1030, pre-medications administered per protocol: ondansetron 8mg IV and dexamethasone 10mg IV. Patient educated on expected side effects and verbalized understanding. At 1045, chemotherapy infusion (docetaxel and cyclophosphamide) initiated through IV line with continuous monitoring. No immediate adverse reactions noted. Patient encouraged to sip fluids during infusion and provided comfort measures.
At 1230, infusion completed without complications. Patient denied nausea or dizziness, stating, “I feel fine, just a little sleepy.” IV line flushed and removed intact. Patient discharged in stable condition with written instructions for home care, including when to report fever or unusual symptoms. Follow-up appointment scheduled for next week.
Example 10: Rehabilitation – Post-Stroke Physical Therapy
09/28/2025 – 1415
Patient is a 67-year-old male in inpatient rehabilitation following ischemic stroke two weeks ago. At 1415, patient participated in physical therapy session focused on gait training and balance exercises. He reported, “I feel stronger today, but my right leg still feels heavy.”
During session, patient ambulated 20 feet using a walker with minimal assistance. Gait observed to be slow but steady, with mild right foot drop. Required verbal cues to maintain upright posture. Blood pressure post-activity 138/86, HR 92, SpO₂ 97% on room air. Patient denied dizziness or shortness of breath.
At 1440, patient completed seated strengthening exercises for lower extremities with good tolerance. Fatigued at end of session but remained cooperative and motivated. Encouraged to continue active range-of-motion exercises between sessions. Education provided to patient and spouse on fall precautions and importance of daily mobility. Patient verbalized understanding. Will continue to progress mobility goals as tolerated.
Tips for Faster, Clearer Narrative Documentation
Writing good narrative notes takes practice, but a few habits can make the process easier and more consistent.
Time Management
- Document in real time when possible. Write notes soon after events occur to keep details accurate.
- Take brief notes during your shift. Record key times, vitals, and patient quotes, then expand later.
- Prioritize urgent events. Falls, medication errors, or sudden changes in condition should be documented immediately.
- Batch routine tasks. For stable patients, group similar charting (such as vital signs or medication administration) to save time.
Clarity and Precision
- Use active voice. Write, “I administered morphine 4mg IV,” instead of, “Morphine was given.”
- Choose strong verbs. Use “assessed,” “educated,” “monitored,” rather than vague terms like “helped” or “did.”
- Include measurable data. Numbers are clearer than general terms (e.g., “200ml drainage” instead of “a lot”).
Consistency and Standardization
- Develop personal templates. Mentally follow a structure: time, subjective data, objective findings, interventions, and response.
- Stick to approved abbreviations. Use standard terms like BP, HR, RR, but avoid unclear shorthand.
- Follow unit-specific rules. ICU notes may need frequent vital signs, while long-term care focuses on function and safety.
Patient-Centered Focus
- Write respectfully. Assume patients or families may read the notes. Replace judgmental terms with objective descriptions.
- Highlight progress. Balance problems with strengths (e.g., “Patient motivated to join therapy despite pain”).
- Acknowledge cultural needs. Include language preferences, religious practices, or family roles when they affect care.
Final Thoughts and Key Takeaways
Strong notes tell the complete picture: what happened, what you did, and how the patient responded. They improve safety, protect you legally, and support communication across the care team.
Start small. Focus on one skill at a time, such as using direct quotes or being more precise with measurements. Over time, your documentation will become faster, clearer, and more confident. Remember, every expert nurse once felt uncertain about charting. Progress comes with practice.
Frequently Asked Questions
Q: How long should narrative notes be? A: Length depends on patient complexity and events during your care period. Simple, stable patients may need 2-3 sentences. Complex patients with multiple interventions may require several paragraphs. Focus on completeness rather than arbitrary length limits.
Q: What if I make an error in my documentation? A: Never use correction fluid or erase errors. Draw a single line through the mistake, write “error” above it, initial and date the correction. In electronic systems, use the facility’s correction process. Document the correct information clearly.
Q: Can I document care provided by another nurse? A: Only document care you personally provided or directly observed. If documenting for an unavailable colleague in emergencies, clearly note “per RN Smith” and include your assessment of the patient’s current status.
Q: How detailed should objective observations be? A: Include enough detail for another nurse to understand the patient’s condition without being present. Use specific measurements, colors, consistency descriptions, and behavioral observations. Avoid vague terms like “appears uncomfortable.”
Q: When is it appropriate to use abbreviations? A: Use only facility-approved abbreviations that appear on your institution’s approved list. When in doubt, spell out the complete term. Avoid abbreviations in critical situations or incident documentation where clarity is essential.
Q: What should I do if I forgot to document something important? A: Make a late entry as soon as possible. Note the current date and time, then write “Late entry for [date/time of actual event].” Document the missed information clearly and explain briefly why the entry is late if relevant.
Q: How do I document difficult or uncooperative patients objectively? A: Describe specific behaviors and quote exact words rather than labeling the patient. Instead of “patient is difficult,” write “patient refused medication stating ‘I don’t want any more pills’ and threw pill cup on floor.”
Q: What’s the difference between nursing notes and progress notes? A: Nursing notes focus on nursing care, interventions, and patient responses. Progress notes may include multidisciplinary input and broader treatment planning. Both serve important documentation purposes, but nursing notes specifically reflect nursing process and decision-making.
Your narrative nursing notes matter. They protect your patients, advance your career, and contribute to healthcare excellence. Master them with confidence.
