Nursing Note Templates and Examples

Updated: March 19, 2024

As nurses, we understand the importance of documentation. Not only does it protect our patients from harm, but documentation also protects our most treasured asset: our nursing licenses! Most Electronic Health Records (EHRs) have templated solutions to fit your workflows; however, these templates do not help nurses develop simplified, streamlined ways to record narrative and communication notes.

Nursing best practices require writing notes in real-time, yet you must balance patient care demands with documentation. This means you chart your interventions later in your shift, leaving room for error. Imagine a solution that prompts structured documentation based on regulatory standards, guiding your conversation with the provider and allowing you to chart during the interaction.

TextExpander is a customizable solution that optimizes your nursing documentation workflow, efficiency, and accuracy. To understand how TextExpander works, let’s first examine the compliant nursing documentation process.

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Compliant nursing notes

Nursing notes are more than just routine documentation; they are integral to patient care and management.

  • Patient monitoring: These notes are critical for tracking patient progress and noting ongoing improvements or issues.
  • Communication: They serve as a vital communication tool between healthcare professionals, ensuring continuity and consistency in care.
  • Legal and regulatory compliance: Detailed nursing notes are crucial for legal documentation, insurance processes, and adhering to healthcare standards.
  • Treatment assessment and planning: These records help evaluate treatment efficacy and plan future care.
  • Care continuity: These notes ensure continuity of patient care and treatment approach.

The most common types of nursing documentation consist of:

  • Admission assessments
  • Flow charts
  • Narrative notes
  • Problem-oriented charting
  • Nursing care plans
  • Medication administration
  • Progress and procedure notes
  • Discharge summaries

To be legally compliant, your notes must also:

  • Be timely, contemporaneous, and sequential
  • Be accurate, relevant, and consistent
  • Be complete, clear, and concise
  • Follow the nursing process
  • Include nursing assessment insights
  • Be retrievable and auditable
  • Follow HIPAA-compliant regulations

Structured documentation styles

Structured nursing documentation styles continue to evolve; from the SOAP notes of the 1990s to the DAR notes of today, templates simplify your documentation with the use of technology and meet legal guidelines.

SOAP notes offer a structured format for recording patient information based on:

  • Subjective: the patient’s personal account of their health and symptoms
  • Objective: observations and measurements
  • Assessment: professional nursing assessment based on the subjective and objective data
  • Plan: outlines the care and treatments for the patient

DAR notes focus on specific issues and are recorded as data, action, and response:

  • Data: relevant, accurate, timely, concise, contemporaneous, and sequential facts
  • Action: actions taken by the nursing staff in response to the data
  • Response: the patient’s response to interventions

SOAP and DAR are only two examples of time-saving nursing documentation tools; follow the policies and procedures of your organization for documentation requirements.

How to write nursing notes quickly with templates

TextExpander is a clever and efficient smart assistant for all of your nursing documentation needs. By creating personalized templates, called TextExpander Snippets, you document in real-time complying with legal, quality, and best practice standards. To illustrate, let’s examine the case studies, below.

Example using the SOAP method

Alex Martinez is a 45-year-old patient admitted to the surgical unit for lower back pain. He has poor range of motion in his lower back and complains of a 7/10 pain score. Alex lives with his wife and young children and is the financial provider for his family. He suffered a football injury in high school and experiences back pain as a result. He is on antidepressant medication, is allergic to penicillin, and is scared surgery will result in paralysis. He is scheduled for spinal surgery in the morning, and you have to call the admission report to the on-call surgeon.

You created a narrative admission note TextExpander Snippet and a quick search term to auto-populate the template. You base your TextExpander Snippet on the documentation requirements of your facility.

Admission assessment TextExpander Snippet Copy Snippet Copied!

Subjective: Patient [name] is a [age], [gender], who is experiencing [symptoms]. Patient reports [special concerns] and is concerned about [specific outcomes or after-care requirements].

Objective: Nursing assessment revealed

  • [Pertinent medical/surgical history]
  • [Pertinent negatives]
  • [Biometrics and vitals]
  • [Medications]
  • [Allergies]

Assessment:

  • [Current symptoms]
  • [Contraindications]
  • [Discharge concerns]
  • [Gaps in care]

Plan:

  • [Orders received]
  • [Orders requested]
  • [Nursing care plan]
  • [Discharge planning]

TextExpander Snippet note output of SOAP note

Subjective: Patient Alex Martinez is a 45-year-old male who is experiencing chronic back pain from a football injury in high school. He is admitted for an elective lumbar laminectomy with Dr. George. Mr. Martinez reports a 7/10 pain score and is concerned about returning to work after spinal surgery. Mr. Martinez expressed fear and depression about his condition.

Objective: 

  • Pertinent Medical/Surgical History: past medical history of a hernia repair in 2015, diagnosed with depression in 2000.
  • Pertinent Negatives: denies chest pain, shortness of breath, abdominal pain, alert and oriented to time, place, and person. Skin is warm, dry, and intact, no evidence of skin breakdown.
  • Biometrics and Vitals:
    • Height: 5’ 10”
    • Weight: 225 lbs
    • Bp: 175/90
    • HR: 90 at rest
    • Resp: 20 at rest
    • Temp: 98.6F*
  • Medications: Zoloft 200mg daily
  • Allergies: Penicillin 

Assessment:

  • Current symptoms: pain 7/10, patient-reported depression, crying during admission assessment, elevated Bp of 175/90
  • Contraindications: surgical protocols call for penicillin, patient is allergic
  • Discharge concerns: lack of mobility, inability to work, financial stress, depression
  • Gaps in care: patient requesting psychology referral

Plan:

  • Orders received: Called Dr. George at 3 pm and reported assessment. 
  • Verbal orders received:
    • Tylenol #3, 1 tab every 4-6 hours for pain as needed
    • Ativan 0.5mg, 1 tab every 6 hours as needed for anxiety
    • Discontinue penicillin and order doxycycline 100mg IV 12 hours before surgery
    • Consult and treat order for physical therapy
    • Consult and treat order for psychology – depression
    • Consult and treat social work – financial and discharge concerns
  • Patient at risk for falls secondary to mobility issues – fall precautions implemented
  • Report called to physical therapy, psychology, and social work for discharge planning

Example using the DAR method

After surgery, Mr. Martinez is back on your floor. He is complaining of pain 10/10 and reports no relief from the Tylenol #3 order given by Dr. George. You call Dr. George to request new pain medication orders.

Problem-focused narrative nursing note TextExpander Snippet Copy Snippet Copied!

Data: [patient reported or nurse assessed needs] 

Actions: I called Dr. [name] on [date] and [time] to [report/request orders] for patient [name], [unit or floor in facility], [diagnosis]. The patient is complaining of [enter symptoms]

Response: [orders received] [actions taken on orders] [patient response to orders/treatments]

TextExpander Snippet note output of DAR note

Data: Mr. Martinez returned from surgery at 11 am and complained of pain 10/10. Tylenol #3 1 tab administered at 1105 am per prn pain orders. At 1145 am, Mr. Martinez continues to complain of pain 10/10.

Actions: I called Dr. George on March 16, at 1147 am to report Mr. Martinez, in room 2A on the surgical floor, diagnosis post lumbar laminectomy pain at 10/10 after administration of 1 tab Tylenol #3 at 11:05 am. 

Response: V.O. received from Dr. George, increase Tylenol #3 to 2 tabs every 4 hours as needed, and administer Dilaudid 2mg tab now. Medication administered at 12 noon. Patient reports pain of 3/10 at 12:20 pm. Patient is resting, with no further complaints.

Create nursing note templates with TextExpander

The practical applications of TextExpander for compliant, streamlined, automated narrative nursing documentation templates are limitless. Imagine completing your documentation during interactions with patients, families, providers, and multidisciplinary teams instead of during your break or at the end of your shift. The boost to your nursing productivity TextExpander Snippets allow you to spend more time with your patients than with your computer! 

Start your FREE 30-day trial today. All you have to lose is your frustration.

Disclaimer: Please note this content is not a substitute for the regulatory policies and procedures applicable to your nursing practice act, therapeutic modality, or organization.

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Patient Information: <br>- Name: [Patient's Name] <br>- Age: [Patient's Age] <br>- ID: [Patient's ID Number] <br> <br>Date and Time: [Date and Time of the Note] <br> <br>Goals of Care: [Specific Goals for the Patient's Care] <br> <br>Interventions and Treatments: [Details of Treatments or Interventions Provided] <br> <br>Patient Response: [Patient's Response to the Interventions or Treatments] <br> <br>Plan Adjustments: [Any Adjustments or Changes to the Patient's Care Plan]
Subjective: Patient [name] is a [age], [gender], who is experiencing [symptoms]. Patient reports [special concerns] and is concerned about [specific outcomes or after-care requirements]. <br> <br>Objective: Nursing assessment revealed <br>[Pertinent medical/surgical history] <br>[Pertinent negatives] <br>[Biometrics and vitals] <br>[Medications] <br>[Allergies] <br> <br>Assessment: <br>[Current symptoms] <br>[Contraindications] <br>[Discharge concerns] <br>[Gaps in care] <br> <br>Plan: <br>[Orders received] <br>[Orders requested] <br>[Nursing care plan] <br>[Discharge planning] <br>
Data: Mr. Martinez returned from surgery at 11 am and complained of pain 10/10. Tylenol #3 1 tab administered at 1105 am per prn pain orders. At 1145 am, Mr. Martinez continues to complain of pain 10/10. <br> <br>Actions: I called Dr. George on March 16, at 1147 am to report Mr. Martinez, in room 2A on the surgical floor, diagnosis post lumbar laminectomy pain at 10/10 after administration of 1 tab Tylenol #3 at 11:05 am. <br> <br>Response: V.O. received from Dr. George, increase Tylenol #3 to 2 tabs every 4 hours as needed, and administer Dilaudid 2mg tab now. Medication administered at 12 noon. Patient reports pain of 3/10 at 12:20 pm. Patient is resting, with no further complaints.
Patient Information: <br>- Name: John Doe <br>- Age: 54 <br>- ID: #54321 <br> <br>Date and Time: November 16, 2023, 10:00 AM <br> <br>Goals of Care: To manage John's postoperative pain following knee surgery and to enhance his mobility. <br> <br>Interventions and Treatments: Administered prescribed pain medication. Assisted with gentle range-of-motion exercises. <br> <br>Patient Response: John reported a moderate decrease in pain levels. He was able to perform limited movements with less discomfort. <br> <br>Plan Adjustments: Schedule physical therapy consultation for more intensive mobility exercises. Monitor pain levels to adjust medication if needed.
Subjective: Patient is Alex Martinez, a 45-year-old accountant experiencing lower back pain. <br> <br>Objective: Reduced range of motion in the lumbar spine. Pain score reported as 7/10. <br> <br>Assessment: The symptoms suggest lumbar strain, possibly due to poor ergonomic posture at work. <br> <br>Plan: Prescribe anti-inflammatory medication and advise on proper ergonomic setup. Recommend physical therapy and schedule a follow-up in one week.

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