How to Write Nursing Notes: A Practical Guide with Examples
A good nursing note lets someone who has never met the patient understand what you saw, what you did and what happened next. This guide covers the habits that make notes clear and defensible.
Clinical review status: awaiting review by a licensed nurse reviewer. Last updated 2026-11-10. Read our editorial policy.
Write what you observed, not what you concluded
Replace general judgements with specific observations. 'Patient comfortable' tells the reader very little. 'Resting in bed with eyes closed, respirations 16 and even, rates pain 2/10' gives them something to compare against.
- Use measurements: centimetres, millilitres, scores and times
- Quote the patient for symptoms and mood
- Name the tool you used, such as the pain scale or risk tool
- Describe behaviour rather than labelling it
Include the full loop
Every significant entry should close the loop: the finding, your action, and the patient's response. If you notified someone, document who, when, what you reported and what they said or ordered.
Timing and order
Chart as close to the event as you can, and never before the care is given. If you need to add something later, write it as a late entry following your facility's policy. Keep entries in time order and do not leave blank space between them.
A fictional before-and-after example
Before: 'Pt anxious. Called doctor. Given meds. Better.'
After: '14:10 Patient pacing in room, states "I can't catch my breath." RR 24, SpO2 93% on room air, HR 104. Sat upright, oxygen applied per protocol. 14:15 provider paged with SBAR report. 14:25 orders received and read back. 14:40 RR 18, SpO2 97%, patient states breathing "much easier".'
The second version is longer, but every line carries information the next nurse can act on. All details are fictional.
Words and habits to avoid
- Unapproved abbreviations, especially those on the Joint Commission do-not-use list
- Blame or opinion about colleagues
- Copying forward previous notes without checking they are still true
- Vague terms such as good, normal, fine or tolerated well without specifics