Guide
Nursing Documentation
Nursing documentation is the timed record of assessment, intervention, and response. Colleges in every province treat it as a professional standard, not optional paperwork. If the next RN cannot see what you found and what you did, the chart failed even if the shift felt busy.
What the record is for
CNO, BCCNM, CARNA, CRNM, and the other provincial nursing regulators say the same thing in different PDFs: document in a timely way, identify yourself, stick to what you observed, and do not leave gaps around medications, risk, and who you notified. CNPS will look at the same pages if a claim lands.
The audience is the next nurse, the MRP, the rapid-response team, and a future you. Billing clerks and quality dashboards are secondary. Write for the person who takes this patient at 19:00.
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for college standards, unit policy, or your own clinical judgment. Review every generated note before it enters the chart.
Sample entry structure
Nursing note (narrative or DAR)
Date / time / unit / bed: Author, designation (RN, RPN/LPN, NP), login: Late entry: no / yes (time of event vs time of writing): D — Data (assessment, patient report, vitals, strips, sugars, wounds) A — Action (what you did, meds given if not fully on the MAR, who you notified) R — Response (what changed) Focus / problem (if focus charting): Safety (restraints, constant care, falls, elopement, suicide observations): Teaching / discharge prep: Plan / to-do for oncoming shift:
Flowsheets hold vitals, intake/output, pain scores, and q15 neuro checks. Narrative holds the meaning: why you called the MRP, what the wound looked like, that the family now has power of attorney papers. Do not duplicate the entire flowsheet in a paragraph. Do not leave a hypotensive episode only as a red number nobody acknowledged.
| Tool | Use it for | Not enough alone |
|---|---|---|
| MAR / eMAR | Doses given, held, refused, with time | The clinical reason you held the beta blocker |
| Flowsheet | Vitals, scores, frequent observations | Notification, interpretation, teaching |
| Narrative / DAR | Changes, calls, wounds, psychosocial, plan | Replacing the MAR with 'meds given' |
| SBAR | Spoken handoff and escalation | A substitute for the timed chart entry after the call |
Example 1 — medicine-surgery shift
Days, post-op bowel resection
63-year-old man, Ottawa. 07:00–19:00. Fictional.
2026-08-28 10:15 RN [name], 7-Surgery, bed 7. D: POD 2 open right hemicolectomy. Alert. Pain 4/10 at rest, 7/10 on transfer, using hydromorphone PCA (attempts 8, delivered 5 last hour). Abdomen softly distended, incision C/D/I, JP 40 mL serosanguinous this shift. Flatus x 1. No stool. Urine 200 mL since 07:00 via Foley. T 37.8, HR 98, BP 118/70, SpO2 96% RA. Glucose 9.4. A: Encouraged sitting in chair 30 min. Incentive spirometer. PCA as ordered. MRP aware of low urine; bolus 250 mL given per protocol. Foley not removed today (MRP: wait for urine >0.5 mL/kg/h). R: Pain 3/10 in chair. Urine 80 mL over next hour. Remains afebrile. Plan for nights: chair TID, watch urine, PCA, incision. Family updated at 11:00.
Example 2 — home care visit
Community RN, wound and meds
78-year-old woman, Thunder Bay. 40-minute home visit. Fictional.
2026-08-28 13:40 RN [name], home care. Client alone, daughter phoned in with consent. D: Venous ulcer left gaiter, 3.2 x 2.1 cm, 0.3 cm depth, 80% granulation, small amount serous, no odour, peri-skin macerated. Pain 2/10. BP 142/84, HR 76, legs dependent edema pitting 2+. Blister pack: missed last night's furosemide (still in slot). Kitchen has food. No new shortness of breath. A: Wound cleansed, zinc barrier on peri-skin, foam dressing, compression as ordered (20–30 mmHg, pulses present). Taught daughter the missed-dose rule for furosemide. Left written sheet. Pharmacy called to add a large-print MAR. MRP clinic message sent re: missed diuretic + edema. R: Client states dressing comfortable. Verbalized when to call (fever, spreading redness, sudden SOB). Plan: RN return Friday. If two further missed diuretic doses, escalate to NP/MRP same day. Not a falls screen today — due next visit.
Example 3 — mental-health unit observations
Inpatient psychiatry, evenings
22-year-old man, London, ON. q15 min observations. Fictional.
2026-08-28 20:10 RN [name], MHU, Rm 3. Level: q15 visual, remaining on unit. D: Admitted yesterday after overdose. Today: ate 50% supper, attended group 15 min then left. Affect restricted. Denied SI on direct ask at 20:00; "I just want to sleep." Room searched per protocol at 19:30 — no ligatures, no extra meds. Visitors: none. A: q15 checks documented on observation sheet (see flowsheet 19:00–20:00). Offered PRN quetiapine 25 mg as ordered; he declined. Redirected to quiet room rather than seclusion. Charge RN aware he left group. No constant-care change. R: Lying on bed, eyes open, answering yes/no. No aggression. Plan: continue q15 overnight. Recheck SI at 23:00 and at handover. Do not rely on this narrative for the actual q15 times — those live on the observation sheet. MRP to review level in AM.
Mistakes that show up on night audit
- Vitals in the flowsheet and no note that the MRP was called for the 86/50.
- 'Patient comfortable' as the entire 12-hour entry.
- Charting by exception that swallows a new confusion.
- Late entries without a label, or a stack of notes written after you have clocked out.
- Copy-forward wound measurements that never change.
- Documenting 'incident report filed' instead of the assessment (follow site policy; the health record still needs the clinical facts).
- Signing a generated note whose MAR times do not match the eMAR.
Paper downtime still happens. Chart on paper in real time. When the EMR returns, enter those notes as late entries. Do not reconstruct a perfect night from memory at 08:00.
Draft the shift note, check it against the MAR
Scribeberry can draft nursing narrative or DAR from dictation or from a recorded huddle, in your unit headings. You still match times to the eMAR and sign. Smart Push into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is nursing documentation?
It is the timed, signed record of a nurse's assessment, actions, and the patient's response, including medications, risk, teaching, and who was notified. Provincial colleges treat it as a standard of practice.
Should I use DAR, SOAP, or narrative?
Use what your unit requires. DAR (Data, Action, Response) and focus charting are common on Canadian wards. SOAP appears more in NP and outpatient notes. The ingredients do not change: findings, what you did, what happened next, plan for the next shift.
How soon do I have to chart?
As close to the event as the shift allows. Unstable changes get an entry when they happen. A whole shift written at the parking lot is a late-entry problem and a memory problem. Follow your employer policy and the college.
Can Scribeberry write nursing notes?
Yes. Dictate or record (with the right consents), generate a DAR or narrative in your template, then edit times, meds, and notifications before the note is pushed to the EMR. You remain the author who signs.
Templates
