How to Write Nursing Progress Notes (SOAP, DAR, PIE): 10 Nursing Progress Notes Examples

Every nurse knows that caring for patients goes far beyond meds and vital signs. The real challenge often lies in documenting what happened — clearly, quickly, and in a way that protects both you and your patient. That’s where nursing progress notes come in. Think of them as the daily story of your patient’s care: what they said, what you observed, the actions you took, and how they responded.

Strong notes do more than fill a chart. They connect the whole care team, prevent errors, and serve as legal proof if questions ever arise. Yet many students and even experienced nurses wonder: How do I write progress notes that are clear, professional, and legally sound?

In this guide, you’ll find nursing progress notes examples you can use right away. You’ll learn what to include in every entry, how to write notes step by step, and the different formats (SOAP, DAR, PIE, and others). You’ll also see real-world examples, side-by-side rewrites, and templates you can download and adapt for your own practice.

What to Include in a Nursing Progress Note (and Why)

Element	What to Document	Why It Matters
Patient Information	Full name, age, ID number; date and time of entry.	Ensures the note is tied to the correct patient and timeline.
Subjective Data	Patient’s own words about pain, feelings, or concerns.	Captures the patient’s perspective and adds context.
Objective Data	Vital signs, labs, physical findings, observable facts.	Keeps documentation factual, measurable, and free from opinion.
Assessment	Nurse’s professional judgment connecting subjective and objective findings.	Links data into a meaningful clinical picture.
Plan / Interventions	Actions taken (medications, wound care, education, referrals).	Shows accountability and next steps for care.
Patient Response	Patient’s reaction, changes, improvement, or decline.	Provides evidence of effectiveness and informs the care plan.
Signature & Credentials	Nurse’s name, role, and credentials (written or electronic).	Completes the note legally and professionally.

How to Write a Nursing Progress Note (Step-by-Step)

Writing a clear, professional progress note doesn’t have to feel overwhelming. By following a simple step-by-step process, you can turn your observations into a note that supports safe care, keeps your team aligned, and protects you legally.

Step 1: Gather subjective and objective data

Start with the facts. Record what the patient tells you in their own words (subjective) and what you can measure or observe directly (objective). Together, these create the foundation of your note.

Step 2: Organize findings logically

Decide which format you’re using (SOAP, DAR, or PIE). Sort your information into the right categories so the note flows in a way others can follow quickly.

Step 3: Document your assessment or analysis

Use your nursing judgment to interpret the data. For example, connect a patient’s report of dizziness with observed low blood pressure. This shows your critical thinking and guides the care plan.

Step 4: Record interventions performed

Write down exactly what you did. Be specific — include the medication given, the dose, or the type of teaching provided. This makes your actions clear and measurable.

Step 5: Note the patient’s response

Did the intervention work? Did the pain decrease? Did the patient demonstrate understanding of the teaching? Always include how the patient reacted.

Step 6: Write the plan or follow-up care

End with next steps. This could be reassessing pain in 30 minutes, scheduling a lab test, or encouraging continued exercises at home. A good plan shows continuity of care.

Quick Checklist (SOAPIE/EHR Workflow)

Checklist Item	Done?
Date and time entered	☐
Patient identifiers included	☐
Subjective data recorded	☐
Objective data recorded	☐
Assessment documented	☐
Interventions noted	☐
Patient response described	☐
Plan/follow-up listed	☐
Signature and credentials added	☐

Formats Explained

Progress notes can be written in different formats depending on your facility’s policy and the patient’s needs. Here are the most common structures and how to use them.

SOAP / SOAPIE / SOAPIER

SOAP is one of the oldest and most widely used formats. Expanded versions add interventions, evaluation, and revision.

Section	What to Include
S – Subjective	What the patient says about their condition (symptoms, concerns).
O – Objective	Measurable and observable data: vital signs, exam findings, labs.
A – Assessment	Your professional interpretation of the data.
P – Plan	Interventions performed or planned.
I – Intervention	(SOAPIE/ER) Specific actions you carried out.
E – Evaluation	Patient’s response to interventions.
R – Revision	Updates or changes to the plan of care.

When to use: SOAP is ideal for complex cases or long-term care, where careful tracking of patient progress is needed.

DAR / DARP (Focus Charting)

DAR is often used in focus charting, where the “focus” can be a patient concern, a behavior, or a nursing diagnosis.

Section	What to Include
D – Data	Subjective and objective information about the focus.
A – Action	Nursing interventions you performed.
R – Response	Patient’s reaction to the interventions.
P – Plan	(In DARP) Next steps or follow-up care.

When to use: DAR is useful for quick, problem-centered documentation, especially in busy units.

PIE Notes

PIE ties directly to the nursing process. Each entry connects to an identified nursing diagnosis or problem.

Section	What to Include
P – Problem	Nursing diagnosis or issue (e.g., “Risk for infection”).
I – Intervention	Specific nursing care provided.
E – Evaluation	Patient’s response and progress.

When to use: PIE is best for facilities that align charting closely with NANDA diagnoses and care plans.

Other Variations (DAP, BIRP, APSO)

Some units use alternate formats that serve similar purposes.

Format	Sections	Best Used For
DAP	Data, Assessment, Plan	General medical-surgical documentation.
BIRP	Behavior, Intervention, Response, Plan	Common in mental health settings.
APSO	Assessment, Plan, Subjective, Objective	Physician-preferred format in EHRs.

When to use: These formats are chosen based on facility policy or specialty needs.

10 Nursing Progress Notes Examples

1. Medical-Surgical Unit

Format: SOAP

Patient: Linda M. Torres
Date: 09/24/2025
Time: 9:10 AM

Ms. Torres, 46, recovering from an appendectomy yesterday, reported mild abdominal pain rated 4/10 this morning. She said she slept through most of the night but woke due to soreness when turning in bed.

Her incision was clean, dry, and intact. Bowel sounds present in all quadrants. She tolerated a clear liquid breakfast without nausea. Vitals stable: BP 122/78, HR 84, T 98.1°F, SpO₂ 98% RA.

Assessment: Stable post-op recovery, pain controlled with medication, early ambulation tolerated with mild fatigue.

Plan: Encourage ambulation every 2 hrs, reassess pain in 2 hrs, continue incision monitoring.

Nurse: C. Reynolds, RN

2. Intensive Care Unit (ICU)

Format: SOAPIE

Patient: Marcus J. Green
Date: 09/24/2025
Time: 2:40 PM

Mr. Green, 62, with traumatic brain injury, remains intubated and sedated. Vitals stable: BP 136/80, HR 92, T 99.0°F, SpO₂ 97% on ventilator (FiO₂ 40%, PEEP 5, rate 16).

Pupils equal and reactive. No spontaneous movement. Propofol infusion at 25 mcg/kg/min. Airway suctioning performed for thick secretions, tolerated well. Skin intact, repositioned q2h.

Intervention: Airway suctioning, repositioning, sedation maintained.

Evaluation: Oxygenation stable, skin intact, family educated about prognosis.

Plan/Revision: Continue vent support, monitor ICP, repeat neuro checks hourly.

Nurse: L. James, RN

3. Emergency Room (ER)

Format: DAR

Patient: Samuel P. Walker
Date: 09/24/2025
Time: 6:55 PM

Data: Mr. Walker, 34, presented with acute chest pain radiating to left arm, pain rated 8/10. Vitals: BP 148/92, HR 112 (irregular), RR 24, SpO₂ 93% RA. ECG showed atrial fibrillation with RVR.

Action: IV access established, labs drawn, O₂ 2 L NC applied. Aspirin 325 mg PO and nitroglycerin 0.4 mg SL given. Placed on continuous cardiac monitor.

Response: SpO₂ improved to 96%. Chest pain decreased to 5/10. Patient less anxious.

Plan: Repeat troponins, monitor closely, prepare for cardiology consult.

Nurse: D. Collins, RN

4. Psychiatric Nursing

Format: BIRP

Patient: Jasmine A. Lee
Date: 09/24/2025
Time: 11:20 AM

Behavior: Ms. Lee, 27, admitted with MDD and SI, attended group therapy. Affect flat but engaged when peers spoke. Reported “less hopeless” but poor sleep.

Intervention: Supportive listening, coping skill reinforcement, sleep hygiene teaching. PRN melatonin 5 mg PO given.

Response: Patient denied current SI, verbalized 2 coping strategies (journaling, calling friend). Participated more actively than yesterday.

Plan: Continue monitoring mood, reinforce coping skills, reassess sleep tonight.

Nurse: H. Martinez, RN

5. Pediatric Nursing

Format: SOAP

Patient: Liam K. Patel
Date: 09/24/2025
Time: 2:05 PM

Subjective: Liam, 6, admitted with pneumonia, reported chest discomfort with coughing. No SOB at rest.
Objective: Vitals BP 98/60, HR 108, T 100.6°F, SpO₂ 95% on 1 L O₂. Diminished RLL breath sounds with crackles. Used incentive spirometer ×5 with coaching. Mother at bedside.
Assessment: Febrile child with lower lobe pneumonia, tolerating fluids and antibiotics.
Plan: Continue IV ceftriaxone, encourage fluids and IS use, monitor for worsening distress, reassess fever in 2 hrs.

Nurse: K. Johnson, RN

6. OB / Postpartum

Format: DAR

Patient: Maria G. Sanchez
Date: 09/24/2025
Time: 10:30 AM

Data: Maria, 29, PPD2 after vaginal delivery, reported perineal discomfort 3/10. Vitals stable, fundus firm at U-1, lochia rubra moderate, no foul odor. Mild perineal edema. Breasts intact, infant latching well.

Action: Assisted ambulation, reinforced peri-care, applied ice pack, gave ibuprofen 600 mg PO, reviewed infection signs.

Response: Patient ambulated with mild discomfort, reported pain relief within 1 hr. Demonstrated proper peri-care.

Plan: Continue ambulation, reassess pain, lactation follow-up tomorrow.

Nurse: R. Williams, RN

7. Wound Care

Format: PIE

Patient: Thomas E. Brown
Date: 09/24/2025
Time: 1:15 PM

Problem: Diabetic foot ulcer, right heel, 2.3 × 1.5 cm, depth 0.3 cm, granulation tissue present, no erythema.
Intervention: Wound cleansed with saline, hydrocolloid applied, gauze dressing secured. Patient educated on foot hygiene and offloading.
Evaluation: Dressing intact, patient verbalized understanding. No infection noted.

Plan: Change dressing q48h, monitor for infection, follow-up podiatry referral.

Nurse: J. Nguyen, RN

8. Home Health / Long-Term Care

Format: SOAP

Patient: Eleanor H. Brooks
Date: 09/24/2025
Time: 4:20 PM

Subjective: Ms. Brooks, 83, reported dizziness on standing.
Objective: BP 152/86 sitting, 138/80 standing, HR 88. Ambulated 15 ft with walker, slow but steady. No falls since last visit.
Assessment: Orthostatic changes likely related to antihypertensives. Mobility safe with walker.
Plan: Educated patient on slow position changes, hydration, confirmed med adherence. Reassess in 3 days.

Nurse: T. Ahmed, RN

9. Hospice Care

Format: DAR

Patient: Robert L. Jenkins
Date: 09/24/2025
Time: 7:40 PM

Data: Mr. Jenkins, 68, with stage IV lung cancer, reported SOB at rest and chest pain 7/10. Vitals: BP 108/64, HR 96, SpO₂ 90% on 3 L O₂. Family present, providing support.

Action: Gave morphine 5 mg SL, repositioned for comfort, applied cool cloth, provided emotional support and teaching to family.

Response: Pain decreased to 3/10, patient more relaxed, family reassured.

Plan: Continue comfort measures, reassess pain, maintain O₂, check-in daily.

Nurse: A. Robinson, RN

10. Post-Op Day 1

Format: SOAPIE

Patient: Caroline D. Nguyen
Date: 09/24/2025
Time: 9:50 AM

Subjective: Ms. Nguyen, 52, post-op day 1 cholecystectomy, reported incisional pain 5/10, mild nausea.
Objective: Vitals stable, incision sites intact, no drainage. Ambulated 20 ft with standby assist, mild dizziness.
Assessment: Stable post-op with controlled pain, mild nausea.
Plan: Ondansetron 4 mg IV, oxycodone 5 mg PO, encouraged ambulation and IS use.
Intervention: Medications administered, patient education given.
Evaluation: Pain decreased to 2/10, nausea improved, patient ambulated again.

Nurse: S. Patel, RN

Legal & Documentation Best Practices

Nursing notes are more than a memory aid. They are legal records of patient care. Courts, regulatory boards, and accrediting agencies may review them. Strong documentation protects both the patient and the nurse.

1. Why Notes Matter Legally

• Evidence of care: Your notes show what you did, when, and why.
  
• Protection in court: If care is questioned, the record is your proof.
  
• Compliance: Hospitals must meet standards from agencies like The Joint Commission, CMS, and state boards.
  
• Continuity: Clear notes help the next nurse pick up without confusion, preventing errors.
  

2. Common Pitfalls to Avoid

• Vague wording → Avoid terms like “patient fine,” “did well,” or “resting comfortably” without details.
  
• Late entries → If you must chart later, always label the note as a late entry with date/time.
  
• Personal opinions → Stick to facts and observations, not judgments.
  
• Copy-paste overuse → Templates are helpful, but copying without updates creates errors.
  
• Unapproved abbreviations → Use only standard abbreviations recognized by your facility.
  

3. Best Practices for Legal Protection

• Chart in real time: Write notes as soon as possible after care.
  
• Be objective: Record what you see, hear, measure, and do.
  
• Include patient/family education: Note what you taught and how the patient responded.
  
• Correct errors properly: Draw a single line through mistakes, initial, and correct them — never erase or delete.
  
• Use quotes for patient statements: Example: Patient stated, “I feel sharp pain in my chest.”
  
• Always sign: Include name, title, and credentials.
  

4. Quick Compliance Tips

• Follow your facility’s policy and EHR guidelines.
  
• If it’s not documented, it wasn’t done (legally speaking).
  
• Keep notes professional — remember patients have the right to access their records.
  
• When in doubt, write it down.

Final Thoughts

Writing clear and accurate progress notes takes practice, but it’s one of the most valuable skills you can build as a nurse. The right note doesn’t just record what happened — it helps your team stay on the same page, shows a timeline of care, and protects you if care is ever reviewed.

The examples in this guide are meant to give you a starting point. Use them as models, then adjust based on your patient, your unit, and your facility’s policies. With time, writing strong nursing progress notes examples will feel like second nature.

Good notes mean safer care, stronger teamwork, and better outcomes for every patient.