Nursing notes are written records that document patient care and serve as a communication tool among healthcare professionals. Patient symptoms, treatment plans, medications are documented in nursing notes to ensure continuity and quality of care. Mastering them early on is vital since nursing notes are not only essential for patient safety but also can have legal implications.
Last updated: December 4, 2023Nursing notes are written records detailing the care provided to a patient, including observations, treatment plans, and interventions. They are essential for continuity of care and are a legal document.
Good nursing notes provide a detailed legal record of a patient’s status, treatment, responses, and outcomes.
All nursing notes must be:
Tips for writing nursing notes:
Writing nursing notes in a narrative format means telling the patient’s story chronologically. The note will provide the information in free, written-out sentences.
An advantage is that notes in this format provide context and a fuller picture of the client’s situation, but they can be time-consuming to read and write.
“SOAP” is short for “Subjective, Objective, Assessment, and Plan”.
Giving nursing notes this structure creates easier reading to scan quickly and reduces the possibility of errors and oversights by providing a standardized, focused documentation.
The SOAP-format is often expanded to “SOAPIE”: Subjective, Objective, Assessment, Plan, Intervention and Evaluation.
An example for this format would be:
Following are examples of nursing note excerpts that show the dos and don’ts of how to follow the requirements of a good nursing note:
Don’t: Patient seems like they are in pain.
Do: Patient grimaced and moaned when their leg was touched.
Interpretations and assumptions are not facts.
Don’t: There was a large amount of drainage.
Do: There was 150 mL of serosanguineous drainage.
“Large amount” as a quantifier leaves the information open to the reader’s interpretation. Stick to the facts and give them in the most detailed way possible.
Don’t: Patient was taught how to check their blood sugar.
Do: Patient was able to correctly return-demonstrate how to check their blood sugar.
Include how the teaching was done and the proof that it was successful.
Don’t: Patient had an elevated temperature after breakfast.
Do: Patient had a temperature of 39.1°C (102.4°F) at 0900.
This example shows again that it is important to be specific, precise, and to give all the available information.
Don’t: Patient had altered mental status, stomach pain, and could not recall their name.
Do: Patient had altered mental status with inability to recall their name and complained of dull stomach pain at a level of 5 out of 10.
Group related information together.
Don’t: Patient uncooperative and would not take meds.
Do: Patient refused 0900 meds.
It is inappropriate to label patients as difficult, uncooperative, or use a negative description – simply state the actions, what happened, quotes stated and everything that may have kept you from taking measures you were supposed to. Leave out any personal perspectives, reactions, or feelings.