Nursing notes examples: four sample notes and what each one gets right

Pick the format before you write

Your facility decides the format, and many electronic records mix flow sheets with free-text notes. Open RN's Nursing Fundamentals text describes four common styles, and each one fits a different job. Knowing which you are writing keeps the note from turning into a shift diary.

Whatever the format, Open RN lists the same basics: date, time and signature; objective, factual language; correct terminology; no unapproved abbreviations; and timely entries. A note written hours later from memory is weaker evidence than one written as care happens.

Narrative and DAR note examples

Sample narrative note, hypothetical: 0215. Client found sitting on edge of bed, states 'I feel dizzy and sweaty.' Skin pale and damp. Blood pressure 92/58, pulse 108, respirations 20, fingerstick glucose 54 mg/dL. Assisted back to bed, call light in reach. Hypoglycemia protocol started and provider notified at 0220. 0235: glucose 98 mg/dL, alert and oriented, skin dry.

Sample DAR note, hypothetical: Data: rates incision pain 7 out of 10, guarding abdomen, pulse 104. Action: repositioned with pillow splint, gave prescribed analgesic, taught splinting for coughing. Response: at 1045 rates pain 3 out of 10, coughs using splint, pulse 88. The response line is the part students skip, and without it nobody can tell whether the action worked.

Wound care note example

A wound note needs enough detail that the next nurse can tell whether the wound is better or worse. Open RN's assessment list covers anatomic location, wound bed, size, wound edges and periwound skin, signs of infection and pain, with length measured on the head-to-toe axis, width side to side and depth at the deepest point. Drainage type and amount, and odor, belong in the note too.

Sample wound note, hypothetical: Left heel, stage 2 pressure injury, 2.5 cm length by 1.8 cm width by 0.2 cm depth. Wound bed pink and moist, small amount of serous drainage, no odor. Periwound skin intact without redness or maceration. Rates pain 2 out of 10 during care. Cleansed with normal saline, foam dressing applied, heel offloaded on a pillow. Tolerated without distress.

If the same wound showed thick yellow-green drainage with red, warm, tender surrounding skin, the note would add a temperature, any culture collected, and who was notified and when. Open RN classes purulent drainage as abnormal and lists redness, hardening, pain, swelling, purulent drainage and odor as signs of local infection.

Head-to-toe excerpt and what makes a note good

Sample head-to-toe excerpt, hypothetical: Neuro: alert, oriented to person, place, time and situation; moves all extremities on command. Respiratory: respirations 18, unlabored, lungs clear bilaterally. Cardiac: apical pulse 76 and regular, pedal pulses present bilaterally. GI: abdomen soft, bowel sounds present in all quadrants, last bowel movement yesterday.

Each line names a system and gives findings, not conclusions. 'Lungs clear' is a finding; 'breathing fine' is an opinion. Put the client's words in quotation marks so readers know the source, and record numbers rather than adjectives, so 'pain 6 out of 10' instead of 'a lot of pain'.

What should not be included in nursing notes

Leave out labels and personal judgments such as rude, drunk or noncompliant; describe the behavior and quote what was said. Leave out vague phrases like good day or no changes when nothing was assessed, abbreviations your facility does not approve, and blame directed at coworkers. Never record care before it happens or findings you did not see yourself.

Corrections follow facility policy rather than erasing or overwriting. If you remember something after leaving, a late entry labeled with the actual time of writing is the honest route; see the related page on late entries and documentation errors for how those are handled.

Sources and further reading

Open RN Nursing Fundamentals: Documentation. Narrative, DAR, SOAPIE and charting by exception formats; date, time, signature; objective language; avoiding abbreviations; timely documentation.

Open RN Nursing Skills: Assessing Wounds. Wound location, length, width and depth measurement, wound bed, drainage types, purulent drainage as abnormal, signs of local infection.

Open RN Nursing Skills: Wound Care Sample Documentation. Sample expected and unexpected wound notes including temperature, culture and provider notification.