“If it wasn’t documented, it wasn’t done.” Every nurse hears it, but few are taught exactly how to write clear, safe and legally sound notes. Good documentation protects patients, supports continuity of care and protects you if your care is ever questioned. This guide gives you examples in the most common formats.
All examples use fictional patients. Always follow your hospital’s documentation policy and use approved abbreviations only.
Golden rules of nursing documentation
- Be timely. Write as soon as possible after care, with the date and time (24-hour clock).
- Be factual and objective. Write what you saw, heard, measured and did. Avoid opinions such as “patient was difficult”.
- Be specific. “Drank 200 mL of water” is better than “drinking well”.
- Quote the patient where helpful: Patient states, “The pain is worse when I breathe in.”
- Record escalation: who you informed, when, and what they advised.
- Never alter notes improperly. Correct errors with a single line, initial and date them, and don’t use correction fluid. For electronic records, follow the amendment process.
- Sign every entry with your name, designation and registration number where required.
- Don’t leave gaps or write for someone else.
- Use only approved abbreviations.
1. SOAP notes
SOAP stands for Subjective, Objective, Assessment, Plan. It’s common in primary care, clinics and many hospitals.
Example: post-operative pain
04/11/2026 14:30
- S: Patient states, “My tummy is very sore when I move.” Rates pain 7/10.
- O: Day 1 post laparotomy. Guarding abdomen. Wound dressing dry and intact. T 37.2°C, HR 98, BP 132/80, RR 18, SpO2 97% on air. NEWS2 1. Last analgesia: paracetamol 1 g orally at 10:00.
- A: Acute post-operative pain, not adequately controlled.
- P: Morphine 5 mg orally given at 14:35 as prescribed (PRN). Repositioned with pillow support. Taught splinting with a pillow when coughing. Reassess pain at 15:30. Inform surgical team if pain not controlled.
Signed: A. Nurse, RN
2. SBAR (for handover and escalation)
SBAR is mainly used for verbal communication, but documenting your SBAR escalation is good practice.
Example: deteriorating patient
04/11/2026 02:15
- S: Bed 12, Mr X, 68, NEWS2 increased from 2 to 6. I’m concerned he may be developing sepsis.
- B: Admitted 2 days ago with a urinary tract infection. On IV co-amoxiclav. History of type 2 diabetes and hypertension.
- A: RR 24, SpO2 93% on air, HR 112, BP 98/60, T 38.6°C, new confusion. Urine output 60 mL over the last 4 hours.
- R: Requested urgent medical review within 30 minutes. Doctor on call (Dr Y) informed at 02:10 by phone. Advised blood cultures, lactate and IV fluid bolus. Will review at 02:30. Observations increased to every 30 minutes.
3. PIE notes
PIE stands for Problem, Intervention, Evaluation. It links directly to the nursing care plan.
Example: risk of falls
04/11/2026 20:00
- P: Risk for falls related to unsteady gait and night-time confusion.
- I: Bed lowered to lowest position, call bell within reach, non-slip socks applied, night light on, toileting offered every 2 hours. Family informed of falls plan.
- E: Patient used call bell twice to go to the toilet with assistance. No falls this shift.
4. DAR (focus charting)
DAR stands for Data, Action, Response, organised around a “focus” such as a symptom or event.
Example: hypoglycaemia
Focus: hypoglycaemia. 04/11/2026 06:15
- D: Patient sweaty and shaky. Capillary blood glucose 3.1 mmol/L. Alert and able to swallow.
- A: 150 mL of fruit juice given as per hypoglycaemia protocol. Recheck after 15 minutes. Doctor informed.
- R: 06:30 blood glucose 5.4 mmol/L. Patient states he feels better. Breakfast given at 06:45. Evening insulin dose to be reviewed by the medical team.
5. Narrative notes
Narrative notes are written in a chronological story. They’re flexible but can become long, so keep them focused.
Example: end of shift summary
04/11/2026 19:30 Patient comfortable throughout the day shift. Observations stable, NEWS2 0–1. Ate 75% of lunch and drank 1,200 mL. Mobilised to the bathroom with a frame and one nurse. Wound dressing changed at 11:00: wound clean, edges approximated, no signs of infection. IV cannula left arm, VIP score 0, flushed at 12:00. Daughter visited and was updated with the patient’s consent. Plan: continue oral antibiotics, aim for discharge tomorrow if physiotherapy review is satisfactory.
6. Documenting a refusal
04/11/2026 09:10 Patient declined 09:00 enoxaparin injection, stating, “I don’t want any more injections, they bruise me.” Explained purpose of the medication (preventing blood clots) and risks of not having it. Patient has capacity and understood the information. Offered alternatives. Patient still declines. Doctor (Dr Z) informed at 09:15, will review today. Medication chart annotated.
7. Documenting an incident
04/11/2026 03:40 Heard a noise from bay 3. Found patient sitting on the floor beside the bed. Patient states, “I tried to go to the toilet by myself.” No loss of consciousness reported. Assessed for injury before moving: small graze on left elbow, no pain on movement of hips or limbs. Observations: BP 128/76, HR 88, GCS 15. Assisted back to bed with two staff using a hoist. Doctor informed at 03:50 and reviewed patient at 04:20. Neurological observations started as per falls policy. Incident report completed. Family to be informed in the morning per patient’s wishes.
Phrases to avoid and better alternatives
| Avoid | Write instead |
|---|---|
| Patient had a good night | Slept from 23:00 to 05:00, woke once for toilet |
| Eating well | Ate full breakfast and half of lunch |
| Patient is aggressive | Patient shouted and raised his fist when asked to return to bed |
| Obs stable | HR 82, BP 124/78, RR 16, SpO2 97% on air, T 36.8°C, NEWS2 0 |
| Doctor aware | Dr Y informed at 14:10 by phone; advised to repeat bloods at 18:00 |
| Wound OK | Wound clean and dry, no redness, swelling or discharge |
Why it matters for international nurses
Regulators and employers abroad expect high-quality documentation. In the UK, the NMC Code requires nurses to keep clear and accurate records. US hospitals use electronic health records with specific charting rules. Practising these formats now will help you in OSCEs, interviews and your first job abroad.