Nursing Note Templates and Examples

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 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.

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.

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.

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

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.

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.

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! 

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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.