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How to write in the medical notes

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• Rachael Brock , clinical lead in national disease registration, Public Health England

What you need to know about good note taking

Medical notes are the backbone of patient care. Good notes facilitate communication between doctors, nurses, and all the allied health professionals involved in the care of the patient. They are a continuous, honest, and contemporaneous record of management and decision making—they help colleagues carry on where you left off. Medical notes are also useful for health professionals when defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time. 1

As a foundation doctor, you’ll be responsible for much of the note taking on ward rounds and during multidisciplinary team meetings. It’s where you’ll document tasks that you have completed and any changes to patient conditions, or vital information from your on-call shifts. As a medical student your team might ask you to write in the notes under the supervision of a junior doctor. This article provides a guide on how to make notes that ensure joined-up care.

What are medical notes?

A patient’s notes consist of ward round notes, consultations—that is, visits from other specialties—results of investigations, and discussions with other professionals, patients, and relatives. Members of the multidisciplinary team such as nursing colleagues, physiotherapists, and occupational therapists also record their care in the notes. Some patients may move wards several times, and clear documentation helps with handovers.

You should follow good practice principles when taking notes. The General Medical Council says doctors should record their work “clearly, accurately, and legibly,” and it also stipulates that patient notes should be created contemporaneously and kept securely. 2 The notes may be scrutinised in medicolegal cases so remember the adage, “if it isn’t written down, it didn’t happen.” Below are guidelines from the GMC and the Royal College of Physicians (RCP) on the content of clinical records.

Box 1: GMC requirements for clinical records 2

Relevant clinical findings

Decisions made and actions agreed, and who is making the decisions and agreeing the actions

Information given to patients

Any drugs prescribed or other investigation or treatment

Who is making the record and when

Box 2: Generic medical record keeping standards approved by the RCP 3 *

The patient’s complete medical record should be available at all times during their stay in hospital

Every page in the medical record should include the patient’s name, identification number (NHS number),† and location in the hospital

The contents of the medical record should have a standardised structure and layout

Documentation in the medical record should reflect the continuum of patient care and should be viewable in chronological order

Data recorded or communicated on admission, handover, and discharge should be recorded using a standardised proforma‡

Every entry in the medical record should be dated, timed (24 hour clock), legible, and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated, and timed

Entries to the medical record should be made as soon as possible after the event to be documented—for example, change in clinical state, ward round, investigation—and before the relevant staff member goes off duty. If there is a delay, the time of the event and the delay should be recorded

Every entry in the medical record should identify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made

On each occasion the consultant responsible for the patient’s care changes, the name of the new responsible consultant, and the date and time of the agreed transfer of care should be recorded

An entry should be made in the medical record whenever a patient is seen by a doctor. When there is no entry in the hospital record for more than four days for acute medical care or seven days for long stay continuing care, the next entry should explain why§

The discharge record/discharge summary should be started at the time a patient is admitted to hospital

Advanced decisions to refuse treatment, consent, or cardiopulmonary resuscitation must be clearly recorded in the medical record. In circumstances where the patient is not the decision maker, that person should be identified—for example, lasting power of attorney

*Prepared by the health informatics unit of the RCPhysicians

†NHS number is being introduced as the required patient identifier

‡This standard is not intended to mean that the handover proforma should be used for every handover of every patient rather that any patient handover information should have a standardised structure

§Maximum interval between entries in the record would in normal circumstances be one day or less

What to write in the medical notes

Ward rounds.

An example of what should be included in the notes as part of the ward round can be seen in figure 1. Write in black indelible ink—it cannot be changed and it is easily photocopied or scanned. ⇓

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Medical students writing in the notes

Medical students can write in the notes, but they should clearly document their authorship and their entry must be countersigned—usually by a junior doctor who verifies the account as an accurate representation of what happened. Writing in the notes is great practice for medical students, and it can free up junior doctors to do other jobs. Sign the notes at the bottom of your entry.

Hospital admissions are usually documented using a proforma, which includes presenting complaint and background information such as medical, social, and family history. The clerking is key to determining comorbidities and usual medications, as well as details of next of kin, which can be vital if the patient deteriorates. The most recent observations, tests, and investigations, as well as a plan for further investigation and management must also be documented. For acute admissions, when a patient’s condition can often change rapidly, document whether the patient seems sick or well, and if he or she is oriented to time, place, and person. This will give a frame of reference for the next doctor reviewing the patient after handover. As well as assisting the registrar with the management of an acutely unwell patient, junior doctors are expected to clearly document all the investigations and management decisions that have been made.

Discharge summaries are read by patients and GPs. They also provide essential information to emergency department doctors if the patient presents with an unexpected complication soon after discharge from hospital. The discharge summary should include the patient’s comorbidities and drugs on discharge as well as accurate details of the admission, findings, and procedures. Follow-up clinic appointments are booked by ward clerks on the basis of the discharge summary alone, so remember to document whether outpatient follow-up is required. It is worth noting that thorough clerking at admission can save you and your colleagues time when filling out the discharge summary.

Be careful when asking GPs to complete tasks. For example, “GP to check outpatient ultrasound scan result” would not be an appropriate request because the clinical team organising a test is responsible for reviewing the results. However, “Patient requested to have repeat liver function tests at GP surgery in one week please” will be better received by the primary care team.

What not to document

Do not make any comments in the notes that you would not make in front of a patient. Particular words you should avoid include alcoholic (although “smelling of alcohol,” or “previous documented alcohol dependency” are appropriate), obese (unless clinically supported by the body mass index—and “raised BMI” might be better), and any words or phrases that could be perceived to have a pejorative tone. Judgmental comments—even when positive (for example, “this charming lady”)—are probably best avoided. Doctors aiming to convey a patient’s individuality in the notes might instead choose to objectively document the person’s home circumstances, interests, or hobbies.

Beware of documenting negative comments about colleagues. Exclamation marks, emoticons, and humour have no place in the medical notes because they can be misconstrued. Documentation should encourage and reflect supportive teamwork.

Particular care should be given to discharge summaries because they are routinely given to patients when leaving hospital. For example, patients with a diagnosis of cancer should be sensitively informed before receiving a copy of a discharge summary detailing this. If the discharge summary is being written by a doctor who has not been involved in the patient’s care this should be clearly stated. Words like “inoperable” or “end stage” should also be used with care. Typos and inaccuracies give a bad impression to the patient, so even if the discharge summary is short, it should be as neat and correct as possible.

Keeping up on the ward round

The quality of the ward round documentation is dependent on the junior team members keeping up with the speed of the ward round. The key is to be quick and efficient. If you think that you do not have enough time to write an adequate entry, raise this as a problem.

Having spare continuation sheets to hand, name stamps, and writing section headings before the consultation can speed up the note taking process. If there is more than one foundation doctor on a ward round, alternating the note taking of patients is often effective.

Other forms of preparation can help the team save time. Blood results and imaging results should be readily available and filed in the patient’s notes. An organised notes trolley, stocked with spare pens and paperwork (continuation sheets, consent forms, and do not attempt resuscitation forms, for example) can also save time.

Further information

Weatherall L, Patel R. How to prepare for a ward round. Student BMJ 2015;23:h4362

Stopford E, Ninan S, Spencer N. How to write a discharge summary. Student BMJ 2015;23:h2696.

Arasaratnam R. Medical ward rounds. Student BMJ 2009;17:b576.

Originally published as: Student BMJ 2016;24:h5703

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

• ↵ Medical Protection. Medical records. 2015. www.medicalprotection.org/uk/resources/factsheets/england/england-factsheets/uk-eng-medical-records .
• ↵ General Medical Council. Good Medical Practice . 2013 .
• ↵ Royal College of Physicians. Generic medical record keeping standards . 2007 .

Medical Note: A Complete Guide for Healthcare Professionals

Table of contents.

As a physician or clinic administrator, you know how important medical notes are for documenting patient care, communicating with other healthcare providers, and supporting clinical decision-making. However, writing medical notes can also be time-consuming, tedious, and prone to errors. This blog post will cover everything you need to know about medical notes. We will also introduce you to Tali, an AI medical dictation and ambient scribe that can help you create accurate and comprehensive medical notes in minutes.

What Is A Medical Note?

A medical note is a written record of a patient’s health history, physical examination, diagnosis, treatment plan, progress, and outcomes. Medical notes are also known as clinical notes, progress notes, or chart notes. Medical notes serve several purposes, such as:

Providing evidence of patient care and clinical reasoning

Facilitating communication and coordination between healthcare providers

Supporting billing and reimbursement processes

Enhancing quality improvement and patient safety initiatives

Contributing to research and education

Medical notes are part of the patient's medical record, a legal document containing all the information related to the patient's health and care. They can follow different formats, such as the SOAP note.  The medical record may include other documents, such as laboratory reports, imaging studies, consent forms, prescriptions, referrals, and discharge summaries.

How To Write A Medical Note?

Writing a medical note can be challenging, especially when you must balance the competing demands of accuracy, completeness, brevity, and timeliness. Here are some general tips on how to write a good medical note:

Write the note immediately after seeing the patient or performing the procedure. This will help you avoid forgetting important details or relying on memory alone.

Use clear and concise language that is easy to understand by other healthcare providers. Avoid jargon, slang, abbreviations, or acronyms that may be unfamiliar or ambiguous to others.

Be objective and factual. Do not include opinions, speculations, or personal comments irrelevant to the patient's care. If you have any doubts or uncertainties about the diagnosis or treatment plan, state them explicitly and explain your rationale.

Be specific. Provide enough information to support your clinical judgment and decision-making. Include relevant data from history taking, physical examination, investigations, interventions, and outcomes. Quantify your findings whenever possible and use standard units of measurement.

Be consistent and organized. Follow a logical structure and format that makes it easy to find and follow the information in the note. Use headings, subheadings, bullet points, tables, or charts to present information in a structured way.

Be comprehensive but concise. Include all the essential information pertinent to the patient's care but avoid unnecessary or redundant information that does not add value or clarity to the note. Use short sentences and paragraphs that convey one idea at a time.

One of the most common formats for writing medical notes is the SOAP format, which stands for Subjective (what the patient says), Objective (what you observe or measure), Assessment (your diagnosis or impression), and Plan (your treatment or management). The SOAP format helps you organize your thoughts and systematically document your findings.

How To Format A Medical Note?

Formatting a medical note can vary depending on the type of note (e.g., admission note, progress note, discharge note), the specialty (e.g., internal medicine, surgery, psychiatry), the setting (e.g., hospital, clinic, home), and the preference of the healthcare provider or institution. However, some general principles apply to most medical notes:

Use correct spelling and grammar. Use a spell checker or a proofreading tool to check your note for errors before finalizing it.

Use punctuation marks (e.g., commas, periods, colons, semicolons) to separate sentences or clauses and improve readability.

Use headings or subheadings to label each section of the note (e.g., History of Present Illness, Physical Examination, Diagnosis, Treatment Plan).

Use indentation or alignment to create a visual hierarchy and separation between sections.

Use bullet points or numbered lists to present multiple items or options concisely.

Use tables or charts to display data or information in a structured way.

Use bold or italic fonts to emphasize important points or keywords.

If creating paper documentation:

Use a standard font size (e.g., 12 point) and style (e.g., Times New Roman) that is easy to read.

Use margins of at least 1 inch on all sides of the page.

Use single or double spacing between lines depending on your preference.

What Are The Common Abbreviations Used In Medical Notes?

When writing or typing, medical notes often use abbreviations to save time and space. However, abbreviations can also cause confusion or misunderstanding if they are not standardized or recognized by other healthcare providers. Therefore, knowing the meaning and context of the abbreviations used in medical notes is important.

There are many types of abbreviations used in medical notes, such as:

Abbreviations for medical terms, conditions, diseases, procedures, tests, or medications. For example, COPD stands for chronic obstructive pulmonary disease, ECG stands for electrocardiogram, and IV stands for intravenous.

Abbreviations for units of measurement, symbols, or signs. For example, g stands for gram, + stands for positive, and < stands for less than.

Abbreviations for directions, frequencies, or dosages. For example, a.c. stands for before meals, b.i.d. stands for twice daily, and i.m. stands for injection into a muscle.

Abbreviations for names of healthcare providers, institutions, or departments. For example, Dr stands for a doctor, NHS stands for National Health Service, and ED stands for emergency department.

There is no universal or approved list of abbreviations used in medical notes. Different specialties, settings, or countries may have different abbreviations or conventions. However, some common sources provide guidance or recommendations on the use of abbreviations in medical notes, such as:

The Joint Commission is an organization that accredits and certifies healthcare organizations and programs in the United States. It publishes a list of abbreviations that should not be used in medical notes because they are considered unsafe or error-prone.

The World Health Organization is an agency of the United Nations responsible for international public health. It publishes a list of abbreviations commonly used in health information systems and documents.

NHS Digital is an executive non-departmental public body of the Department of Health and Social Care in the United Kingdom. It publishes a list of abbreviations commonly used in the NHS App and other health records.

Are There Any Legal Requirements For Medical Notes?

Medical notes are legal documents that can be used as evidence in court cases, audits, investigations, or complaints. Therefore, medical notes must comply with the legal requirements and standards of the jurisdiction where they are created and stored. Some of the common legal requirements for medical notes are:

Accuracy : Medical notes must reflect the truth and reality of what happened during the patient encounter. They must not contain false, misleading, or inaccurate information that could harm the patient or the healthcare provider.

Completeness : Medical notes must include all the relevant and necessary information related to the patient's care. They must not omit significant details or facts that could affect the patient's outcome or the healthcare provider's liability.

Timeliness : Medical notes must be written immediately after seeing the patient or performing the procedure. They must not be delayed, backdated, or altered after the fact.

Legibility : Medical notes must be written clearly and readable so that other healthcare providers can understand. They must not be illegible, incomprehensible, or ambiguous.

Confidentiality : Medical notes must be kept in a secure and private place accessible only to authorized persons. They must not be disclosed, shared, or copied without the patient's consent or a valid legal reason.

How To Ensure Patient Privacy In Medical Notes?

Patient privacy is a fundamental right and a legal obligation for healthcare providers. Patient privacy means that patients have control over who can access their personal health information and how it can be used. Healthcare providers must respect and protect patient privacy by following the principles of confidentiality, consent, and security.

Confidentiality means that healthcare providers must not disclose or share patient information with anyone who is not involved in the patient’s care or who does not have a legitimate need to know. Healthcare providers must also ensure that patient information is not accidentally or intentionally leaked, lost, or stolen.

Consent means healthcare providers must obtain patient permission before collecting, using, or disclosing patient information. Consent can be expressed (e.g., written or verbal) or implied (e.g., inferred from the patient's actions or circumstances). Consent can also be withdrawn at any time by the patient.

Security means that healthcare providers must take reasonable steps to safeguard patient information from unauthorized access, use, modification, destruction, or disclosure. Security measures may include physical (e.g., locks, alarms), technical (e.g., passwords, encryption), and administrative (e.g., policies, procedures) controls.

Can Patients Access Their Medical Notes?

Patients can access their medical notes under certain conditions and limitations . Patients can request access to their medical notes from their healthcare provider or institution by following the established process and providing the required information. Patients may have to pay a fee to obtain copies of their medical notes.

Patients can access their medical notes for various reasons, such as:

To review their health history and progress

To verify the accuracy and completeness of their information

To share their information with other healthcare providers

To exercise their legal rights or pursue a claim

However, patients may not be able to access their medical notes in some situations, such as:

When the access would pose a serious threat to the patient’s health or safety

When the access would violate another person’s privacy or confidentiality

When the access would interfere with an ongoing investigation or legal proceeding

When access is prohibited by law or regulation

Can Medical Notes Be Shared Between Healthcare Providers?

Medical notes can be shared between healthcare providers involved in the patient's care or who have a legitimate need to know. Sharing medical notes can facilitate communication and coordination between healthcare providers and improve the quality and continuity of care for patients.

However, sharing medical notes also entails risks and responsibilities for healthcare providers. Healthcare providers must ensure they share medical notes only with authorized persons and for authorized purposes. Healthcare providers must also ensure that they share medical notes securely and appropriately, which respects patient privacy and confidentiality.

Some of the common methods of sharing medical notes between healthcare providers are:

Paper-based : Healthcare providers can print out copies of medical notes and send them by mail, fax, courier, or hand delivery. This method is simple and familiar but also slow and unreliable.

Electronic : Healthcare providers can use email, text, or instant messaging to send electronic copies of medical notes. This method is fast and convenient but also vulnerable to hacking, interception, or misuse.

Online : Healthcare providers can use online platforms, such as portals, networks, or cloud services, to upload, store, and share medical notes. This method is efficient and accessible but also dependent on internet connectivity, compatibility, and security.

Verbal : Healthcare providers can communicate medical notes verbally by phone, video call, or face-to-face conversation. This method is direct and personal but also prone to misunderstanding, distortion, or omission.

Medical notes are essential for providing quality patient care and ensuring legal compliance. However, writing medical notes can also be daunting and time-consuming for healthcare providers. We created Tali, an AI medical dictation and ambient scribe that can help you create accurate and comprehensive medical notes in minutes.

Tali is a smart and easy-to-use solution that captures the relevant information from your patient encounter and generates a structured and formatted medical note that follows the SOAP format. Tali saves you time and hassle by eliminating the need for typing, clicking, or scrolling.

With Tali, you can focus more on your patients and less on your paperwork. Tali helps you improve your productivity, efficiency, and satisfaction as a healthcare provider. Tali also helps you improve your patient outcomes, satisfaction, and loyalty by providing them with better care and communication.

If you want to experience the benefits of Tali for yourself, you can try it for free today .

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Understanding and Implementing Medical Transcription: A Comprehensive Guide

Medical Dictation Software: A Complete Guide for Healthcare Professionals

A medical note is a comprehensive written record that documents a patient's health history, physical examination, diagnosis, treatment plan, progress, and outcomes. Often referred to as clinical notes, progress notes, or chart notes, medical notes serve various functions. They provide evidence of patient care and clinical reasoning, enable communication and collaboration among healthcare providers, aid in billing and reimbursement processes, enhance quality improvement and patient safety initiatives, and contribute to research and education. These notes are an integral part of a patient's medical record, which contains all information pertaining to their health and care, including documents like laboratory reports, imaging studies, prescriptions, and discharge summaries.

Writing effective medical notes can be challenging due to the need to balance accuracy, brevity, completeness, and timeliness. To achieve this, healthcare professionals should write the note shortly after interacting with the patient or conducting a procedure. Clear and concise language should be used to ensure easy understanding by other healthcare providers, avoiding jargon and abbreviations that may be unclear. Objectivity is key, meaning opinions or speculations irrelevant to the patient's care should be excluded. Specificity is also crucial; the note should include relevant information from history taking, physical examination, tests, interventions, and outcomes, quantifying findings where possible. Following a logical structure, such as the SOAP format (Subjective, Objective, Assessment, Plan), helps organize thoughts and systematically document findings.

Medical notes are legal documents that must adhere to the legal standards and regulations of the jurisdiction in which they are created and stored. These notes must be accurate, complete, timely, legible, and confidential. Patients' privacy rights must be respected and protected, ensuring that personal health information is not disclosed to unauthorized individuals. This is achieved through confidentiality, consent, and security measures. Healthcare providers must obtain patient consent before using or disclosing their information, and security measures, both physical and technical, must be in place to prevent unauthorized access or disclosure. Patients can typically access their own medical notes, though restrictions may apply in certain situations, such as when privacy, safety, or legal proceedings are at stake. Sharing medical notes among healthcare providers is permissible, but precautions must be taken to ensure security and proper authorization.

Writing an Effective Patient Note with Documentation Guidelines

A patient note is the primary communication tool to other clinicians treating the patient, and a statement of the quality of care. EHRs aim to assist you in writing a patient note, but in the end, the note comes from you, the physician or caregiver, not from the EHR. Your EHR can help you write a better note, but it can also make a note more difficult to read. By following some documentation guidelines, you can write a strong and concise note, no matter what EHR you use.

When approaching notes, ensure you follow the two acceptable formats, SOAP (subjective, objective, assessment and plan) or APSO (assessment, plan, subjective, objective). There are two suggested steps to document an effective and informative note, and four sections (SOAP or APSO) that you will want to include in a patient note.

• Step one is to review the relevant medical history including any previous notes for the patient so that the patient’s status is fully understood.
• Step two is to verify that the patient has adhered to the previous treatment plan—taking prescribed medications, completed diagnostic testing, primary and referral visits, adhering to diets, etc.

Crafting an Effective Patient Note

After these steps are completed, you can start your effective and informative note, keeping in mind that the note should be as concise as possible. We’ll follow SOAP for our example.

In the subjective section (S), start the note by identifying previous notes that were reviewed by referencing the past notes into the current note. Most EHRs allow you to copy and paste previous notes, all lab results, radiology reports and other sections of the chart into your note. However, copying and pasting previous notes should be avoided given the risks of inclusion of irrelevant or inaccurate information as well as the risk of excessively long notes (also referred to as note bloat). Ensure the documentation of the patient’s chief complaint(s) and any new problems are clearly stated. Also, document the patient’s degree of adherence to the treatment plans from the previous visits.

The section that follows should be objective (O), documenting the physical exam associated with the chief complaint(s) and any new problems. Be sure to highlight any changes in the examination, document any relevant diagnostic testing (i.e., laboratory, radiology, pathology) associated with the chief complaint(s) and any new problems.

If any other items on the problem list complicate the current chief complaint(s) and any new problems, then include those problems and how/why they contribute to the current chief complaints and/or new problems.

Ensure you avoid note bloat by taking the following steps:

• Only include medications that are being used to treat the chief complaint(s) and new problems, the entire medication list is not necessary.
• If the visit is not for the treatment of allergies or an allergic reaction, do not include the patient’s allergies into the note.
• Items on the problem list that do not impact current treatment should not be brought into the note.

The third section will be the assessment (A). Document the differential diagnosis based upon the information recorded in the subjective and objective areas of the note.

You will conclude with the fourth section—the treatment plan (P). In this section, document any continuing and new plan(s) and the thought process behind it. This includes any diagnostic or therapeutic procedures performed during the encounter or to be ordered after the visit, medications prescribed, etc. Document any changes to existing treatment plan(s) and the thought process behind the treatment plan(s).

The final step is to review the note prior to signing and make sure it reads clearly and is straightforward. The note is your tool to communicate with yourself on future visits and other providers who may care for the patient.

Most importantly when you’re writing patient notes: keep your audience in mind, that’s the other members of the patient’s care team, and in many cases the patient themselves. Documentation burden affects not only the writer of the note, but also the readers. So think of the famous saying attributed to Blaise Pascal and many others: “I’m sorry to write you this long note, I didn’t have time to write a short note .” Take the time, avoid the EHR’s note-bloat temptations, and keep it short and concise.

The views and opinions expressed in this content or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.

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Nursing documentation is essential in healthcare service, whether you are a new nurse graduate , a nursing student, or have years of experience.

Table of Contents

Knowing how to chart all the required documentation is vital for your professional integrity and the safety of yourself, your patients , and your colleagues. Furthermore, in the nursing profession, accurate documentation is a legal requirement. 

Nurses’ notes are among the most essential documents for the healthcare team. Keep reading to know why nursing notes are so important, why it is crucial to take good notes, how to do it, what information is needed, how to find the right balance, and more.

What Is a Narrative Nursing Note?

A narrative nursing note is one type of nursing documentation that gives important information about the patient. It usually encloses one or two paragraphs that include the patient's care, their response to the treatment, and the interventions and education the nurse provides for the patient.

Nursing notes let other multidisciplinary team members know what interventions nurses performed on the patient. These notes may include subjective data (the patient telling you how they feel) and objective data (the nurse assessing the situation and the treatment for the patient).

Taking nursing notes can prove to be quite challenging, and it is a skill you must practice as a nurse.Most nursing schools spend significant time stressing the importance of charting. Knowing what to write and when to do it, including subjective or objective data, and understanding the balance between being too detailed and too vague are the keys to writing good nursing notes. So, let’s start with the essentials and analyze some examples of practical nursing notes.

Characteristics of Effective Nursing Notes with Examples

Effective nursing notes have the following characteristics:

• Medical Terminology: Use the correct vocabulary and clinical terms when writing nurses’ notes. When referring to what a patient said, you can use quotation marks. For example, the patient says she “used her inhaler” before coming to the hospital.
• Caution: Be observant and gather enough information to make informed clinical decisions. For example, if somebody else wrote that a patient was oriented to name, place, time, and situation—but you have doubts—you should double-check during your assessment.
• Detail: When you write nurses’ notes, you must describe what you did and said to the patient. Most nurses prefer to make notes as soon as they finish with a patient to avoid forgetting anything potentially important. Of course, you need to find a balance so the notes are not too long but cover all relevant details. Remember that notes will come in handy to asses that same patient later.
• Readability: Most healthcare facilities use digital charting systems nowadays, but if you need to handwrite your notes, they should be clear and readable. Write well-structured sentences with the active voice instead of the passive voice. For example, “ I educated the patient on the correct use of her medication” instead of “patient was educated on medication.” As you can see from the nurse's notes examples, effective communication is vital when writing them.

Tips for Writing Effective Nursing Notes

These tips can help you significantly improve your nursing notes:

• Be specific and stay on topic.
• Use short sentences.
• If possible, use bullet points.
• Add small details that you consider essential.
• If the patient has more than one condition, it is crucial to prioritize the more significant condition in the notes.
• Sign the nursing note.

Remember, when you are writing nurse notes, always be clear, avoid grammar or spelling mistakes, and ensure other team members will be able to understand the notes. This includes utilizing the correct symbols; omissions must be crossed out with a single line. Never delete or use whiteout to correct a nursing note.

What Is the Difference between Charting and Nursing Notes?

There are many documents nurses need to fill out or create when taking care of their patients. One of them is charting, which includes institution-specific requirements. Charting differs from nursing notes because all healthcare professionals use charting for the patient and documenting the medications, physical examinations, interventions, etc. On the other hand, nursing notes narrate a nursing care encounter with a patient. Notes might vary in length; however, good nursing note examples always describe the nurses’ decision-making process with that specific patient.

Electronic Charting Nursing Notes

Healthcare IT systems for facility documentation record the treatments administered to patients and their data. They can help improve the nursing process and the delivery of care. Most nursing charting and nursing note examples in electronic format are easier to read and understand and, at the same time, improve communication of patients’ data and records, given that all healthcare providers use the same information.

Nurses must know how to use the charting system for each facility in which they work. Nurses’ notes differ from other nursing documents and are valuable for clinical practice.

Standard Templates for Nursing Notes

There are many templates for nursing notes. Here, we will describe three of them based on their mnemonics:

This mnemonic stands for Data, Action, and Response, and it is a template that can be as short or long as a nurse needs it to be.

DAR Example

This is another common mnemonic used in nursing, especially for nursing notes. It stands for Subjective, Objective, Assessment, Plan, Implementation, and Evaluation. It is more structured than DAR and helps healthcare professionals communicate both thoroughly and concisely. This form accurately depicts the plan of care at all steps. Some nurses also use the acronyms SOAP (including the first four points of consideration) or SOAPIER (including Revision).

SOAPIE Example

The World Health Organization endorses ISBAR , a system adapted from the United States Navy (SBAR) to ensure proper communication among all parties. When all healthcare professionals use the same language, the specific template doesn’t affect the outcome as long as all parties are clear on important details and are appropriately trained in the method. ISBAR stands for Introduction, Situation, Background, Assessment, and Recommendation.

ISBAR Example

This last method is widely used for referrals, so it needs to be brief but detailed enough so the person receiving it can quickly understand what follow-up actions are required.

Overall, whatever the format, a nursing note must include the following:

• The nurse’s name and role.
• The patient’s name.
• The date and time of the nursing note.
• A description of the nursing process.

A Sample of Nurse’s Note

The following is an example of a nurse’s note:

Renal Vasculitis Nursing Note (Fictional Example)

• Pulse = 110 beats per minute
• Respiration = 24 breaths per minute
• Temperature = 98.2 degrees Fahrenheit (F)
• Blood Pressure = 130/90

Example of Good Progress Nursing Notes

Nursing notes can be progressive for the same patient, for example, with inpatients in hospitals , long-term care facilities , or any healthcare setting where the patient stays for a couple of days or more.

Other Considerations for Writing Nursing Notes

Remember that with per diem jobs , you may not be at a facility longer than one shift. Since you may not be available to explain what you observed or what needs to be done with a patient, having high-quality nursing notes will be essential for the healthcare professionals who care for the patient after you.

• Remember always to write your nursing notes as soon as you can. Memory can fail you if you take too long. Charting as you go will help ensure accuracy and effective nursing notes.
• As you can see, the format when taking notes will vary from facility to facility, so if you are ever in doubt during a per diem shift, feel free to ask colleagues. It’s better to ask questions than to omit information the facility requires.
• Try to use precise language in your nurse notes, and if you have to handwrite them, use a blue or black pen. Never use a pencil for charting nursing notes.
• If you are new to the process of taking nursing notes, you can take short notes for yourself while assessing the patient; that way, you will have most of the information later.
• Remember, nursing notes are accessible to the medical team and are valuable so everybody can access accurate, concise, and specific information regarding the patient.

Perhaps one of the most critical questions is, “If I received this note, would I be able to continue with the care the patient needs?” If the answer is yes, you did it well and are ready to go. 

Continue improving your nursing skills by reviewing how to perform a head-to-toe nursing assessment .

• ANA: Principles for Nursing Documentation
• Narrative Nursing Note Examples
• An Analysis of Narrative Nursing Documentation in an Otherwise Structured Intensive Care Clinical Information System

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Our clinical notes take a lot of time to write. Is it time well spent?

SARINA SCHRAGER, MD, MS

Fam Pract Manag. 2022;29(4):3-4

Clinical office notes communicate what happens within the examination room. The progress note is a tool for clinicians to convey information to each other to optimize the care of our patients. I read notes from specialists to help my patients navigate their care. These notes explain to me why a certain medication was prescribed or a specific test was ordered during the visit. I can also determine whether the patient understood what the consultant or one of my partners told them in another office visit. I rely on my own notes to remind myself what I was thinking during the patient's previous visit, especially if it was a long time ago. Why did I order that test? What was I thinking when I made that diagnosis? A well-written note is essential to patient-centered care.

It is no surprise to any clinician that these notes take a lot of time to write. A recent study showed that the average physician spends a mean of 1.77 hours daily on documentation outside of normal office hours. 1 EHRs have not improved the efficiency of writing notes; they have actually made completing documentation more cumbersome. In their classic 2017 paper, Arndt and colleagues described the burden of EHR documentation on primary care clinicians. 2 In this study, for each hour of direct patient care, clinicians spent two hours interacting with the EHR. Excess documentation for billing purposes only increases the administrative burden.

Many of us worked during a time when handwritten notes were the norm. They were shorter and did not include problem lists, medication lists, or extensive reviews of systems. The documentation was limited to the story (history or subjective), exam (objective), assessment, and plan. Note templates in the EHR, on the other hand, often include extensive supplemental data, much of which exists elsewhere in the record.

Recent studies have evaluated how notes are read. A 2015 cognitive task analysis of 16 primary care physicians found that the assessment and plan sections of office progress notes were reviewed first and were rated as the most important components of the note. 3 Some organizations have recommended a change from the traditional SOAP notes (subjective, objective, assessment, and plan) to APSO notes (assessment, plan, subjective, and objective), which may save clinicians time and improve the usability of the EHR. 4 Preliminary data demonstrates clinician satisfaction with the APSO note format in both outpatient and inpatient arenas. 5 , 6

OpenNotes is an initiative in the recently implemented 21st Century Cures Act. It provides patients with access to all notes written by their physicians, other medical providers, and care teams. The ability for patients to access notes may be beneficial. With more complete information, patients can engage more fully in their care. Initial data suggests that most patients find it helpful to read their notes. 7 , 8 On the other hand, a small study documented that more than 10% of patients were offended or felt judged by something the clinician wrote. 9 The use of stigmatizing and judgmental language in notes is not unusual 10 and may be more common in notes written about people of color. 11 One study looking at history and physical notes from an emergency department found that negative language was included in charts of Black patients 2.55 times as much as White patients. 11

As note writing in medicine evolves, we must continue to focus on tools that enhance its efficiency in primary care. The 2021 Medicare guidelines relieved clinicians of some of the burden of note writing by decreasing billing requirements. We need to continue looking for ways to reduce the amount of time clinicians spend writing notes, while at the same time paying attention to implicit bias in our notes.

Gaffney A, Woolhandler S, Cai C, et al. Medical documentation burden among U.S. office-based physicians in 2019: a national study. JAMA Intern Med . 2022;182(5):564-566.

Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med . 2017;15(5):419-426.

Koopman RJ, Steege LMB, Moore JL, et al. Physician information needs and electronic health records (EHRs): time to reengineer the clinic note. J Am Board Fam Med . 2015;28(3):316-323.

Belden JL, Koopman RJ, Patil SJ, Lowrance NJ, Petroski GF, Smith JB. Dynamic electronic health record note prototype: seeing more by showing less. J Am Board Fam Med . 2017;30(6):691-700.

Lin CT, McKenzie M, Pell J, Caplan L. Health care provider satisfaction with a new electronic progress note format: SOAP vs. APSO format. JAMA Intern Med . 2013;173(2):160-162.

Sieja A, Pell J, Markley K, Johnston C, Peskind R, Lin CT. Successful implementation of APSO notes across a major health system. Am J Accountable Care . 2017;5(1):29-34.

Walker J, Leveille S, Bell S, et al. OpenNotes after seven years: patient experiences with ongoing access to their clinicians' outpatient visit notes. J Med Internet Res . 2019;21(5):e13876. 2020;22(4):e18639.

Chimowitz H, Fernandez L. Sharing visit notes: getting patients and physicians on the same page. Fam Pract Manag . 2016;23(6):10-13.

Fernandez L, Fossa A, Dong Z, et al. Words matter: what do patients find judgmental or offensive in outpatient notes?. J Gen Intern Med . 2021;36(9):2571-2578.

Park J, Saha S, Chee B, Taylor J, Beach MC. Physician use of stigmatizing language in patient medical records. JAMA Netw Open . 2021;4(7):e2117052.

Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: documenting racial bias in the electronic health record. Health Aff (Millwood) . 2022;41(2):203-211.

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A step-by-step guide to taking perfect clinical notes

Clinical record keeping is integral to good professional practice and quality healthcare. But as healthcare changes with new technology and reimbursement models, so should clinical documentation.

Whether you’re a medical student, resident, or established physician with decades of experience, it can be helpful to go back to the basics. In this step-by-step guide to taking perfect clinical notes, we will cover the following:

Why write clinical notes

• The importance of context
• What to include in a clinical note

Tips for better clinical documentation

Basic legal considerations, open clinical notes.

• How to keep documentation efficient

Please remember that this guide is intended as a helpful reminder and compilation of best practices. It is not legal or medical advice. When questions arise regarding clinical documentation, providers should always refer to their specialty-specific training and published legal guidelines. 

As a busy doctor, high-quality documentation can become a low priority. But remember that medical records are much more than an annoying task on your to-do list.

There are three fundamental reasons to strive for perfect clinical notes. 

• Communication – A patient record is a form of communication. Good documentation informs future providers, including yourself, what happened and how you arrived at a treatment plan. It’s the most important way to facilitate high-quality patient care. 
• Legal – The medical record is a legal document that may be heavily scrutinized in the case of malpractice. It is, therefore, crucial to document sensitive discussions regarding limits of care, prognosis, and treatment decisions. 
• Reimbursement – Clinical notes are a service document. Whether you are self-employed or work for a hospital, medical documentation supports reimbursement. Clear, complete, and accurately coded documentation translates into your businesses’ or your employer’s cost and revenue lines.

Whenever you change your documentation style or workflow, it’s helpful to remember why you write clinical notes in the first place. Consider how the information you decide to include – or not include – affects the medical records’ efficacy as a form of communication, a legal document, and as a service document. 

Get the context right

Before getting into the content of a clinical note, remember to check the context . For example, are you writing in the correct patient chart? Have you included the date and time? Will the next person to read the note know who wrote it?

These questions are so basic they are easy to overlook. However, minor context errors lead to enormous time loss and negative patient health impacts. Before starting your note, make sure to check the following: 

• Patient name – Does the name on the chart match the patient you examined? Confirming the patient’s identity is especially important in a digital context, where clicking the wrong button or opening the wrong window can be easy. 
• Date/time – Did you include the correct date and time of your encounter? Time is critical in emergency or ICU settings, but it can also be easy to miss if you are catching up on clinical notes at the end of the day. 
• Heading – Include a descriptive header if multiple providers might edit the note. For example, “Surgery progress note” gives important context if you’re in a hospital or multi-disciplinary outpatient setting. 
• Signature – Make sure to sign every entry with your name and title.

How to write a SOAP note

Start your clinical note by briefly summarizing the main presenting issues. For example, “81-year-old male presenting with pneumonia.” Then, use the SOAP method to write your notes clearly and consistently.

SOAP stands for Subjective, Objective, Assessment, and Plan. It’s a helpful acronym for remembering the main elements of any clinical note.

This section describes the patient’s story as you understand it. Providers typically use a narrative form to describe the patient’s chief complaints, including onset, chronology, quality, and severity. Document what the patient tells you about how they feel and what happened, in their own words, using direct quotations as appropriate. 

Use the Objective section to document the measurable or objective facts about the patient’s status. These facts could include how you observe the patient (“Patient appears pale and in discomfort…”), vital signs, or other findings from your physical examination (“Widespread expiratory wheeze on auscultation of the chest…”), and any relevant laboratory results. 

The assessment is your primary medical diagnosis or an interpretation of what “S” and “O” mean. If someone has already made a diagnosis, comment on whether the patient is clinically improving or deteriorating. The assessment should summarize a complete list of diagnoses for hospitalized patients every 1-2 days. 

Document a precise treatment plan, meaning what happened as a result of you seeing the patient. The plan could include further investigations, referral procedures, new medications, or other prescribed therapies.

While the SOAP method is a helpful starting format, structuring your documentation this way doesn’t guarantee a perfect clinical note. 

Here are some additional tips for excellent clinical documentation:

• Make entries as soon as possible after providing care. Prompt documentation reduces the risk of forgetting key details. It also ensures other team members know about changes to the patient’s condition or management plan. While this isn’t always possible, do the best you can. If you consistently complete clinical notes long after patient visits, talk with your colleagues about how to improve your documentation workflow . 
• Be thorough. Remember that the core purpose behind documentation is communication. Future readers will have a different context than you have, so include all the essential details as clearly as possible. 
• Be brief. Brevity isn’t just about getting through your documentation efficiently; it also helps your care team. Other providers need your note to quickly communicate important information with as little extraneous detail as possible. 
• Be clear. Avoid using abbreviations or ambiguous terms. If you alter or revise a clinical note, remove information using a strikethrough and sign/date your correction. 

Strict laws govern the handling and content of clinical records, whether you’re in the United States or another country. In general, these exist to support three aims: 

• accuracy and legibility of clinical records content;
• confidentiality and data protection; 
• and patient access to medical records. 

We’ve summarized the following reminders from published research , but always ensure you know the relevant legal requirements for your context. 

Accuracy and legibility of clinical records content

From a legal perspective, there are a few elements to make sure you include in a clinical note. The first is relevant clinical findings, meaning your professional diagnosis and evidence to support your plan.

You also want to include a record of decisions made and actions agreed on, as well as who made the decisions and agreed to the steps. Finally, record the plan and any other information given to the patient. Remember that from a legal perspective, if something isn’t recorded in the clinical notes, it didn’t happen.

Confidentiality and data protection

In the digital era, confidentiality means that you don’t share patient information without consent and that your entire care team takes the necessary steps to protect patient data. 

Rules vary by country, but practitioners in the United States will want to review the HIPAA Privacy Rule . Work with your care team to ensure you’re taking the necessary steps to protect patient data and address potential health IT security risks. The Office of the National Coordinator for Health Information has a helpful seven-step approach for implementing a security management process . 

Patient access to medical records

Patients have a right to access their medical records, and laws are changing to protect this right more fully. In the U.S., a new federal privacy rule gave patients access to clinical notes starting in 2021. That means clinicians and hospitals must provide patients with easy access to their health information, including notes and test results, in a fully automated, low-cost manner. 

As discussed below, this legal requirement means that “perfect clinical notes” may look different today than they did in the past.

In 2021, an ONC enacted the Cures Rule , requiring all hospitals and clinicians in the U.S. to make full clinical notes readily available to patients. For some providers, this patient rights win didn’t change anything because many healthcare organizations had already adopted an ‘open notes ’ policy. In fact, before the Cures Rule, 250 healthcare organizations already offered open notes to more than 50 million patients registered on their portals. 

However, with open notes now the norm, some providers may want to adjust the content or tone of their notes. In an article titled “Your Patient Is Reading Your Note,” published in The American Journal of Medicine , the authors suggest seven tips for implementing open notes in clinical practice:

• Be clear and succinct
• Directly and respectfully address concerns
• Use supportive language
• Include patients in the note-writing process
• Encourage patients to read their notes
• Ask for and use feedback
• Be familiar with how to amend notes

You can find a compilation of tips and examples for those suggestions in this toolkit . 

How to keep clinical documentation efficient

We would be remiss not to emphasize that perfect clinical notes are notes you complete efficiently. 

At a time when most physicians spend over 15 hours each week on clinical documentation and other paperwork, physician burnout is a serious risk. 

Here are seven tips for getting clinical notes done on time : 

1. Leverage the skills of your team members

You don’t have to document everything yourself. Strategically involve other team members to ensure everyone’s time is used wisely.

2. Complete most documentation in the room

Many providers have found that dictating clinical notes during patient visits saves time and provides ancillary benefits. 

For example, when talking with a patient about their health history or treatment plan, summarizing aloud can double as your dictation and a way to engage the patient, improve understanding, and ensure accuracy. Consider completing most documentation in the exam room whether you dictate or type . 

3. Know the E/M documentation guidelines

Save time by adhering to the guidelines and only documenting what’s medically necessary to complete today’s visit. For example, a 99213 level of service, the code used 61 percent of the time by family physicians seeing Medicare patients, does not require a comprehensive review of systems or a comprehensive exam.

4. Use essential EHR functions

Templates , for example, are helpful for routine visits where clinical queries are standard. Manual typing – or mobile dictation – may be the fastest option in complex or changing situations. But if it’s flu season, save time by creating a basic influenza vaccine template.

See more tips on how to optimize your EHR workflow .

5. Perfect clinical notes won’t be perfect

The EHR can be a black hole for perfectionists and compulsive “box-checkers.” Know what matters, and leave the rest alone. Not all boxes need checking, and not all categories need filling on every visit. 

6. Forget the “opus”

Remember that the clinical note is not a biography. In the plan section of the note, be clear and concise, including only what’s necessary so that the next person who reads it can understand your reasoning. 

7. Time yourself

Use a timer and see how long it takes to complete a note. Using this baseline, set a goal to decrease the time it takes you to write each patient note.

Remember that excellent clinical documentation results from initial training and continuing education. As healthcare changes, how you document will change, too. Periodically review your documentation and EHR workflow and make adjustments as necessary.

In summary, perfect clinical notes meet basic clinical and legal requirements and fit within your clinical workflow.

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Your note, your way: how to write an inpatient progress note accurately and efficiently as an intern

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Miao Wei, Efrain Salgado, Christine E Girard, Jonathan D Santoro, Natasha Lepore, Your note, your way: how to write an inpatient progress note accurately and efficiently as an intern, Postgraduate Medical Journal , Volume 99, Issue 1171, May 2023, Pages 492–497, https://doi.org/10.1136/postgradmedj-2022-141834

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A physician’s progress note is an essential piece of documentation regarding key events and the daily status of patients during their hospital stay. It serves not only as a communication tool between care team members, but also chronicles clinical status and pertinent updates to their medical care. Despite the importance of these documents, little literature exists on how to help residents to improve the quality of their daily progress notes. A narrative literature review of English language literature was performed and summated to provide recommendations on how to write an inpatient progress note more accurately and efficiently. In addition, the authors will also introduce a method to build a personal template with the goal of extracting relevant data automatically to reduce clicks for an inpatient progress note in the electronic medical record system.

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Nail Nursing Notes Now, Prepare Yourself for the Future

Taking nurses notes is a regular practice in patient care. But putting together nursing notes can be a little tricky – you want to be able to capture all the information you need in as few words as possible, but you also don’t want to leave out any important details.

Writing nursing notes is one of the core responsibilities of being a nurse, and learning how to write them effectively and quickly will set you up for success in your future career.

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Nursing notes vs. charting, how are nursing notes used, what do you write in nursing notes, nursing notes examples.

• How to Write Nurses Notes

The most effective nursing notes include terminology, observance, detail, and readability. Whether you’re in clinicals or on the job, it’s important to understand why and how they’re crucial to providing quality care.

We’ll show you what goes into nursing notes and how to write them effectively for the best patient care.

But first, let’s get into how they’re relevant to charting.

Nursing students learn charting (along with notes) early and often to better paint a picture of the patient’s health at the time of the visit or for the duration of the time. Charting includes the notes made by nurses and put into a computer.

Charting information is purely objective (IV site documentation, alarms, test results, etc.), and are set up specifically for each working medical facility. 

Making quick notes when evaluating the patient will enable you to chart more quickly and provide more accurate nurses’ notes immediately.

Read here to learn how notes and charts fit into the nursing process .

The first thing to know about nursing notes is that they’re not just for patients but also for nurses. Nurses notes fill documentation gaps between doctors, patients, and other providers.

The primary purpose of a nursing note is to track the progress of the patient’s condition over time. 

You also may share notes with other team members, depending on their role within the department. This allows them to adjust treatments accordingly if necessary (e.g., increasing dosage).

In short, you write everything you observe as a nurse and any significant medical information. Nursing notes include information about how the patient feels, what they need, and what’s going on with their health in a short, detailed summary. 

When you put every piece of information together, make sure that everyone who needs to know about a patient’s care can access that information quickly and easily.

What’s Included in a Nurses Note?

The information included in a nurses note varies depending on the facility’s needs and the type of care being provided. Nurses notes are often filled with abbreviations and medical jargon – which you and staff will know, but the patient most likely won’t.

Generally, here’s what you can expect from your nurse’s notes:

• General patient information: name, gender, age, address.
• Reason for their visit & Chief complaint: What they came in for and how long they’ve been under your care.
• Observations: What you’ve observed during your time with them (what they look like when they’re awake or asleep, their breathing patterns and heart rate, etc.).
• Treatment plan : A care plan layout based on the collection, analysis, and organization of nurses’ clinical data.
• History: Patient history including present and past ailments.
• Medication(s): Any medications given to the patient (including dosage details), along with medication history.
• Ending summary: An overall evaluation of their condition at the time of discharge.

Ideally, you should take brief notes while you’re in the same room as the patient, and add more detail as soon as you leave the patient’s room while the information is still current and fresh in your mind.

The following are four nursing notes examples varying between times of a patient’s admittance:

Acute Pancreatitis Nursing Note

Patient Name and Age: Kane Schneider, 33

Date: May 14th, 2022

Chief Complaint: The patient’s chief complaint is acute pancreatitis, which they developed after eating a large amount of greasy food. The patient also reports that they have been experiencing nausea and vomiting since they arrived at the hospital.

Diagnosis: Acute Pancreatitis

History: The patient reports that they have had similar symptoms in the past and have had several episodes of acute pancreatitis over the past few years. The patient has had all of their gallbladders removed in attempts to treat this condition.

The patient has not been taking any medication for nausea, but has been receiving IV fluids for hydration due to their vomiting.

Physical exam: Vital signs are stable — pulse = 72 beats per minute, respirations = 16 breaths per minute, temperature = 98.2 degrees Fahrenheit (F). Physical examination reveals a pale and diaphoretic person in moderate distress with abdominal tenderness on palpation in the epigastric area. 

No jaundice or bruising is present on examination of the skin or mucous membranes. Abdominal distention is present with peripheral edema noted around the umbilicus area as well.

Urinary Tract Infection Nursing Note

Patient Name and Age: Elaina Hassan, 77

Date: January 29th, 2022

Chief Complaint: She has been experiencing fever, chills, and dysuria for two days. 

History of Present Illness: Patient has previously experienced mild hypertension and heart failure.

Physical exam: Vitals – The patient’s temperature is 99 degrees Fahrenheit. The pulse is 100 beats per minute and regular. The blood pressure is 140/90 mm Hg.

Diagnosis: Urinary tract infection.

Assessment: She appears to be in moderate distress and is slightly tachycardic at 104 beats per minute. Patient demonstrates evidence of right lower quadrant tenderness on palpation as well as suprapubic tenderness on deep palpation. The patient’s urine dipstick test reveals 1+ blood and no white blood cells or nitrites present in her urine sample.

Evaluation: She has been treated with antibiotics and fluids, and can now urinate without discomfort.

Alcohol Withdrawal Nursing Note

Patient Name and Age: Willie Brandt, 41

Date: March 21st, 2022

Diagnosis: Alcohol withdrawal

Assessment: Patient was brought in by his family for alcohol withdrawal. When they brought him in, he was experiencing tremors, hallucinations, and confusion.

History: Patient has been drinking alcohol for 24 years, and his family noticed that he started to drink more heavily over the past few years.

Plan of care: Monitor vital signs every 15 minutes; check urine output every hour; administer IV fluids as ordered; administer medication as ordered (e.g., benzodiazepines); monitor electrolytes every 6 hours or as ordered; provide emotional support to patient and family; educate patient on how to avoid future episodes.

Upper Respiratory Infection Nursing Note

Patient name and Age: Jazmin Adkins, 25

Diagnosis: Upper respiratory infection, including rhinitis and pharyngitis.

Assessment: Patient presented with symptoms of a cold, including runny nose, sore throat, cough, and congestion. Symptoms have persisted for 2 weeks.

History: Patient works as a bartender at a local restaurant. Two evenings per week she works late into the night and does not get enough sleep; she also drinks alcohol on these nights (about 4 drinks). 

She washes her hands frequently at work but does not use hand sanitizer before touching his face or putting his hands in his mouth. Patient often smokes cigarettes outside work hours and is always around cigarette smoke when out with friends or family members who smoke regularly.

How to Write Nurses Notes – General Tips 

Sometimes it can be hard to know where to start, or how to make your notes stand out from the rest of your peers. 

When writing a nurse note, you must first think about what is important for the patient. But it’s also important to ask yourself: what’s important for the rest of your team? 

Here are some simple tips for writing the perfect nursing note:

• Stay on point and be specific . 
• Use shorter sentences when possible for easier reading.
• Include interdisciplinary team members . 
• Use bullet points when possible (it’s much easier to scan through a list than long paragraphs).
• Sign each entry of your note with your name and credentials .
• Use correct grammar and spelling (and avoid autocorrect). 
• Add new information throughout the patient’s visit .
• List a patient’s most important condition and its severity level (for patients with multiple conditions).
• Don’t forget the smaller details .

Include patients’ room and bed numbers at the top of the page (if you’re writing a note for an inpatient).

Take Your Nursing Learning to the Next Level

Taking nurses notes will be one of many, many job responsibilities you’ll have. You’ll be better prepared for success in your future work if you can write them efficiently, promptly, and with the maximum amount of detail.

You’ll have great nursing notes when you can quickly balance medical terminology, writing skills, detail, and observation.

To get all of that down easier and more efficiently, you’ll need a supplemental resource. SimpleNursing offers just about everything you need (study guides, question banks, assessments, and more) to perfect your nursing process.

Get the most out of your nursing courses and effectively put them together in your studies.

Unlock these resources with a free trial today .

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How to Write Patient Progress Notes [+ Example]

Table of contents.

Nurses are with the patient more than any other provider on the healthcare team, so you carry a big burden as a nurse to keep close watch over your patients and document every single detail of their care — no pressure though!

Below, I’m sharing what goes into good patient progress notes, from what they are to how to write them. 

What Are Patient Progress Notes?

Patient progress notes are used to keep a record of a patient’s care when they are staying at a hospital. Nurses, doctors, physical therapists, and all other members of the healthcare team who provide care to the patient will document notes in the patient’s chart. All progress notes can be accessed by the members of the healthcare team in order to keep everyone aware of what is going on with the patient’s condition and care. 

As a nurse, you will spend a lot of time reading patient progress notes as well as writing your own. Many nurses start their shift by reading through progress notes to get an idea of what’s going on with the patient and to prepare for their day of caring for them. 

How to Properly Write Patient Progress Notes

Even though you won’t be the only healthcare provider writing patient progress notes, your notes as a nurse are some of the most important because you’ll be spending more time with the patient than any of the other providers. Here are some tips to follow to help you write effective patient progress notes.

Include essential information

There are essential pieces of information that should be included in every patient’s progress note.

Every patient progress note should include:

• Date and time
• Name of the patient
• Identification of the nurse who is writing the note
• An overview or general description of the patient
• Clinical assessment
• Any incidents that occurred
• Any changes noticed by the nurse (such as changes in the behavior, well-being, or emotional state)
• Any changes in the care (such as shift change to a new nurse or new orders placed by a doctor)
• Recommendations for further care

Use subjective and objective data

You should use subjective and objective data to craft a nursing note. Subjective data include information that the patient has provided, such as their pain level and their perspective. Objective data are what you have observed or gathered as the nurse, such as the patient’s visible state, their vital signs, or other clinical markers of their condition. 

Make sure to distinguish between these two things when documenting. You can write things like “the patient states their pain level is a 10 and that they feel nauseous”. To gather subjective data prior to writing a nursing note, ask the patient questions about how they are feeling. 

Use the nursing process as a guide

Whether you’ve just started nursing school or you’ve graduated, you’re likely familiar with the nursing process. I personally remember having this concept drilled into me as a brand new nursing student.

The nursing process is as follows:

• Diagnosis (nursing diagnosis)
• Intervention 

The nursing process is a great guide for progress notes because it covers all bases. Remember, nurses can’t diagnose in the same way that doctors can, so you can discuss nursing diagnoses (such as pain or risk of infection) or you can note what the doctor has stated as the diagnosis.

Types of Nursing Documentation

Students and new graduates are often confused by all the different forms of nursing documentation. Here are some examples to help you distinguish them. 

1. Charting

If you haven’t already, you’ll soon realize that charting is a big part of being a nurse. Charting includes all documentation of the patient’s care that is documented in the patient’s computerized chart. When charting patient assessments, you’ll use a computer-based spreadsheet to go through each body system and plug in information such as the patient’s pain level, how their lungs sounded, what their pulse felt like, etc. Progress notes are one aspect of charting. 

2. Progress notes

Progress notes are the written notes that you’ll add to your patient’s chart when any changes occur. If the patient’s condition starts to decline or there are any changes in the patient’s care, then you will want to put a note in the chart so that it is documented. Progress notes are not only written by the nurse but by all of the providers who see the patient. 

3. Handwritten notes

As a nurse, you will likely also keep some handwritten notes ( I know I did). Handwritten notes are a helpful way to jot down information as it’s happening if you’re not able to get to a computer right away. 

4. Verbal communication at shift change 

Another form of important communication as a nurse is the handoff report that you will give and receive at the end and start of each shift. This is an overview of each patient that is shared between nurses when a shift is changing. You’ll likely use your handwritten notes when giving your handoff report to the next nurse. 

Why Is Documentation Important for Nurses?

Documentation is crucial for nurses because it helps to ensure proper patient care.

Nurses use patient progress notes to learn about new patients and their conditions, then they use progress notes to keep track of a patient’s care throughout their hospitalization. Progress notes are used by all members of the healthcare team to get an idea of how a patient is progressing throughout their hospitalization.

If for some reason a patient’s condition declines, documentation can be used to look back and determine whether any of the healthcare providers are at fault. In the rare case that a patient or their  family decides to sue the hospital because of medical negligence, the nurses’ notes are some of the main documentation that will be used and looked at to determine what happened in the patient’s case. Many nurses use progress notes as a method to “cover themselves” in the case of a lawsuit. If you clearly documented every aspect of the patient’s care that you were involved in, you’re less likely to be blamed for whatever went wrong. 

When Should You Write Progress Notes?

Every hospital will be a little different when it comes to how they prefer to have charting and progress notes performed. Some nurses enter progress notes at shift change, some write them with each patient assessment – it just varies. Ask your supervisor or the other nurses on your unit about how they prefer progress notes be written. If you have any issues with your patient, such as a decline in their condition or a transfer to a more critical unit, this would be a time when you should include a progress note. 

Tips for Writing Effective Progress Notes

Writing strong patient progress notes is a skill that you will develop with time and experience as a nurse. In the meantime, you can follow some of these tips to help ensure that your progress notes are effective and informative. 

Follow your workplace’s protocol

Asking your supervisor and other nurses on your unit can help you determine whether there is a specific format that you’re supposed to follow when writing patient progress notes. Every hospital will be a little different in what they prefer. 

Use the facts

Try to be as objective as possible when writing patient progress notes. Include the facts and observations that are essential to help a person understand the situation at hand. Objective information ensures accuracy and understanding for anyone who reads the notes. 

Keep it concise

Try to avoid including unnecessary information in your progress notes, despite possibly wanting to include it (such as stating that the patient called you a name or was rude to you). Adding anecdotal information to a progress note waters down the actual purpose of the note and pulls the attention of whoever reads it away from the important information. Not to mention, it is unprofessional!

Review the notes of other nurses

If you’re new to nursing (or still in nursing school)  take some time to review examples of other nurses’ progress notes for their patients to get an idea of what a strong progress note looks like. 

Example of a Patient Progress Note

Here is an example of a patient progress note that includes all the necessary information: 

Date: 02/15/2023 

This RN (Sophia) found the patient slumped over in bed. Upon assessment, the patient was found to be cold and sweaty. This nurse was able to wake the patient by tapping them on the arm and stating their name, but the patient remained in a disoriented, drowsy state. The patient’s speech was slurred and their eyes were glazed over. Vitals were taken. Blood pressure 125/45; Pulse 65; Blood glucose 50. This RN notified the physician, orders were given. Glucagon administered. Blood glucose rechecked and found to have increased to 100. The patient began to become more lucid and awake, speech became clearer. Will continue to monitor. 

Final Thoughts

Writing strong patient progress notes is an essential part of being a nurse, but just like with any other nursing skill, it will take time and practice to get good at writing them. Do your best to be clear and concise and include all of the pertinent information when writing patient progress notes. 

My name is Sophia. I am a Registered Nurse with experience working as a floor nurse on a Renal Care Unit and Hematology/Oncology Unit.

Further Reading

How to Practice Clinical Skills at Home

The Hardest Class in Nursing School

Writing Notes for Studying in Nursing School

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5 Perfect Nursing Progress Notes Examples + How to Write

If you are a nurse, you know one of the most important parts of our jobs is to document about our patient’s status, the care they receive, and their response to any treatments. There are many types of documentation nurses and other healthcare professionals use. One type of documentation is a nursing progress note. If you are new to nursing or unsure about the different types of documentation, you may wonder, “What is a nursing progress note?” In this article, I will tell you about nursing progress notes, what they are, their purpose, and the advantages and disadvantages of using them. I will also share 5 perfect nursing progress notes examples + how to write them. At the end of this article, I will answer some frequently asked questions about nursing progress notes to give you more insight into these important documents.

WHAT IS A NURSING PROGRESS NOTE?

What is the purpose of writing a nursing progress note, is a nursing progress note the same as a nursing progress chart, 3 advantages of nursing progress notes, advantage #1: nursing progress notes keep patient information accessible, advantage #2: you can use nursing progress notes to promote positive patient outcomes, advantage #3: nursing progress notes create a legal record of the care you provide, 2 disadvantages of nursing progress notes, disadvantage #1: it is time-consuming to create nursing progress notes, disadvantage #2: it is easy for the nursing progress note to become repetitious, what elements should be included in a nursing progress note, 1. subjective data:, 2. objective data:, 3. nursing assessment findings:, 4. planned nursing interventions:, 5. patient response to interventions:, what elements should not be included in a nursing progress note, 1. jargon or meaningless phrases should not be included:, 2. avoid providing unnecessary information:, 3. another nurse’s opinion or statement about a patient:, 4. unapproved medical abbreviations should be avoided:, 5. care not yet given should never be documented:, how to write a perfect nursing progress note, step #1: begin the nursing progress note with relevant information, step #2: provide a general description of the patient and the reason for their visit/encounter, step #3: perform a patient interview to obtain subjective information, step #4: gather essential objective data and record your findings., step #5: describe proposed treatment plan, step #6: document nursing interventions, step #7: document the patient’s response to care or treatment provided, what are the perfect examples of nursing progress notes, bonus 7 most common mistakes to avoid while writing nursing progress notes, mistake #1: adding irrelevant or unnecessary information, about the mistake:, how to avoid:, mistake #2: making assumptions, mistake #3: using incorrect or unapproved abbreviations, mistake #4: writing sloppy notes, mistake #5: waiting too long to write your note & forgetting important facts, mistake #6: not reviewing progress notes from previous shifts, mistake #7: not documenting care or interventions, my final thoughts, frequently asked questions answered by our expert, 1. who can write a nursing progress note, 2. when to write a nursing progress note, 3. do nurses write progress notes every shift, 4. ideally, how long should nursing progress notes be, 5. what’s the most important part of a nursing progress note, 6. what are the 5 legal requirements of nursing progress notes.

• Documentation must be centered around the nursing assessment and nursing interventions that should occur. • The note should document previous conditions and responses to treatments as well as changes in the patient’s health condition and any new interventions to be implemented. • The nursing progress note must reflect the extent of care needed, such as continuous care, the patient’s needs, and any interventions initiated to provide that care. • HIPPA Privacy Rules must always be upheld. • The nursing progress note must be clear, legible, and contain accurate information.

7. Can I Use Abbreviations In A Nursing Progress Note?

8. what tense do i write a nursing progress note, 9. are nursing progress notes handwritten or printed, 10. how to sign off nursing progress notes, 11. what happens if i forget to write a progress note on the time it should have been written, 12. can a nursing student write a nursing progress note.

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