Clinical template
Nursing Notes Template with Examples
A nursing note records what you assessed, what you did, and how the patient responded on this shift or visit. Use the blank below, then three fictional Canadian notes written the way an RN or RPN would chart after a med-surg shift, a mental-health observation, or a home-care wound visit.
Blank nursing note template
Copy this into the EMR flowsheet narrative, a paper kardex addendum, or a Scribeberry custom template. Many Canadian units use DAR (Data, Action, Response) or focus charting. Keep the same facts if your unit prefers SOAP or narrative.
Nursing note (DAR / focus)
Date / time (24 h): Unit / visit type: inpatient / ED / community / virtual Nurse: [name, designation RN / RPN / NP] | Patient: [initials, age, room or address] Focus / problem: D — Data (what you assessed) Subjective (patient or caregiver words): Objective: vitals, pain scale, focused exam, drains, lines, wound, behaviour, intake/output Results available this shift (glucose, INR, culture, last analgesic): A — Action (what you did) Interventions, medications given (drug, dose, route, time), education, who you notified, orders obtained R — Response (what happened after) Reassessment time, pain/vital change, whether the intervention worked, outstanding issues for the next nurse Safety / isolation / code status (if changed or relevant): Handoff items:
Fictional patients
Every example on this page uses made-up names and findings. They are teaching material. They are not a substitute for CNO, BCCNM, CRNA, or other college standards, or for your unit's documentation policy. Review every generated note before you sign.
What belongs in a nursing note
The next nurse, the MRP, and, years later, a college investigator should be able to see what you found, what you did, and whether it helped. Flowsheets hold the vitals. The narrative holds the exception, the call to the physician, the refusal, and the teaching. Do not rewrite the entire head-to-toe in every entry if the unit already has a completed assessment; chart the change.
| Section | What belongs here | What does not |
|---|---|---|
| Data | This assessment: pain, wound, behaviour, vitals you took, patient quotes | Yesterday's assessment copied forward as if it were tonight's |
| Action | What you administered, taught, or escalated, with times and names | 'Will continue to monitor' with no action |
| Response | Reassessment after the action, timed | Hopeful statements with no numbers or observed change |
| Handoff | What the next nurse must do in the next 4 hours | A full biography or a diagnosis you are not making |
Canadian nursing colleges (CNO in Ontario, BCCNM in B.C., CRNA in Alberta, and their counterparts) expect timely, factual, unaltered entries. Late entries are labelled as late. Errors are struck through per policy, not deleted. An AI draft that you did not read is still your signature.
How to write so the next nurse can act
Time every entry in 24-hour clock. Quote the patient when the words matter ('I can't catch my breath lying flat'). Put numbers in Data: pain 7/10 at 14:10, 3/10 at 15:00 after hydromorphone 0.5 mg SC. Name the physician you called and the order you received. 'Dr. notified' without a name or an order is a hole in the chart.
Action is concrete. Repositioned left-side-lying, dressing changed using sterile technique, 0.9% NaCl flush to PICC, education on incentive spirometer x 10 breaths. If the patient refused, write the refusal, what you explained, and what you did next. Response is the second look. If you gave an opioid, you owe a sedation and respiratory reassessment, not only a pain score.
Community notes need the environment: stairs, pets, who is in the home, whether supplies arrived. Mental-health notes need observation level, what you actually observed (not 'psychotic'), and any PRN with indication and effect. Do not chart a roommate's name or a family conflict in language you would not read aloud in court.
Example 1 — med-surg, post-op hip
Inpatient surgical unit, evening shift
72-year-old woman, POD 1 right THA, Halifax Infirmary. Fictional.
21:10 Focus: pain and neurovascular status, R hip POD 1 D: Patient states "the thigh is throbbing, I can't get comfortable." Pain 7/10 at rest, 8/10 on small movement. Last hydromorphone 0.4 mg SC at 17:45. Vitals 21:05: BP 152/84, HR 92, RR 18, SpO2 96% RA, T 37.1. R foot warm, capillary refill <2 s, sensation intact to light touch, dorsalis pedis present. Dressing dry. Hemovac 40 mL serosanguineous this shift. No calf tightness. Alert, oriented x3. A: Positioned with abduction pillow, ice to lateral hip x 20 min. Hydromorphone 0.5 mg SC given 21:15 per order. Incentive spirometer encouraged. Dr. Patel (ortho on call) paged 21:20 re: pain not controlled on current q4h dosing; new order hydromorphone 0.5 mg SC q3h PRN and add acetaminophen 1 g PO q6h. R: 22:00 pain 3/10, RR 14, drowsy but rousable, SpO2 95% RA. Neurovascular unchanged. Hemovac 45 mL cumulative. Handoff: next PRN due no earlier than 00:15; watch sedation; physio in a.m. for first stand. Patient agrees to call bell before standing.
Example 2 — mental-health unit, observation
Inpatient psychiatry, constant observation
28-year-old man, day 2 after overdose, London ON. Fictional.
14:40 Focus: suicide risk, observation level, PRN agitation D: On 1:1 observation since admission. Sitting in chair, staring at floor, minimal speech. When asked about safety: "I still think they'd be better off without me. I'm not going to do anything here." No suicide plan or means on unit (belongings searched on admission). No AH reported this shift. Pacing started 14:10 after a phone call with his partner; voice raised, punched mattress once, no injury, no attempt to leave the unit. Vitals 14:00: 128/78, HR 88, RR 16. A: Remained 1:1, door open, no other patients in room. Offered quiet space and water. Lorazepam 1 mg PO given 14:25 for agitation per PRN (indication: escalating motor agitation after call). Charge RN Chen informed. MRP Dr. Singh notified; observation to remain 1:1; no privilege change. Belongings re-checked: no extra clothing cords. R: 15:10 sitting, quieter, "the med took the edge off." No further hitting. 1:1 continues. Handoff: next check of ligature risk at shift change; partner asked not to call this evening (patient request, documented). Evening staff: do not leave bathroom door closed.
Example 3 — community wound visit
Home care, venous ulcer
64-year-old man, Saskatoon. 40-minute nursing visit. Fictional.
10:35 Focus: left medial gaiter venous ulcer, compression, education D: Patient: "the leaking is better but the itch is worse." Lives in a walk-up, one flight, partner present. Ulcer L medial gaiter: 3.2 x 2.1 cm (was 3.8 x 2.4 cm two weeks ago), 80% red granulation, 20% yellow slough, no odour, no surrounding erythema spreading, periwound macerated. Moderate serous exudate on old dressing. Pedal pulses present. Cap refill <3 s. Pain 2/10 during dressing. Temp 36.5, no fever. Ankle circumference 24 cm (unchanged). Compression stockings on incorrectly (rolled at the top) when I arrived. A: Cleansed with potable water, pat dry. Hydrofiber to base, silicone foam, then 20–30 mmHg compression wrap applied toe-to-knee after Doppler ABI 1.05 on file (last week, home-care PT). Taught partner not to roll the wrap. Left extra dressings. Reminded elevation 30 min TID. Called wound-care NP (Lee) to confirm continue compression; no antibiotic indicated. Next visit booked Thursday. R: Patient and partner return-demonstrated wrap start at the toes. No pain after wrap. Handoff for Thursday: re-measure, photo if EMR allows, watch for increasing erythema or fever — then same-day clinic, not wait for next visit.
Mistakes that show up in charts
- Charting ahead ('will give 22:00 meds') before the act.
- Copy-forwarding a wound description that no longer matches the bed.
- Omitting the name of the physician and the actual order after an escalation.
- Pain medication without a timed reassessment of pain, sedation, and respiratory rate.
- Judgmental language ('difficult,' 'non-compliant,' 'drug-seeking') instead of behaviour and quotes.
- Leaving a 1:1 or a restraint episode with no start time, indication, or least-restraint alternative.
- Signing a generated note that still says 'patient' in every sentence and never names the focus.
College complaints and CMPA-adjacent hospital files often turn on gaps: the fall that was not in the note, the PRN with no indication, the allergy that was verbal and never charted. If it is not in the record, it is hard to show it happened. Correct the AI draft in the same sitting you sign.
DAR, SOAP, and narrative on the same unit
DAR is focus charting. SOAP works if the unit already thinks that way; keep Data from mixing into Assessment. Narrative is fine for a two-line 'slept, ate 50%, no complaints' night entry if the flowsheet is complete. Pick one structure per entry so the next reader is not hunting for the action.
Draft the nursing note from the shift
Scribeberry takes dictation or the visit audio and drafts DAR or narrative in your headings. Edit times, doses, and who you called, then Smart Push into the EMR. Pro is $99/month after the free trial.
Frequently asked questions
What should a nursing note include?
Time, focus, what you assessed, what you did (including drugs, doses, and notifications), and a timed response. Add safety, isolation, and handoff items when they affect the next nurse. Flowsheets can hold routine vitals; the note holds the exception and the clinical reasoning.
Is DAR better than SOAP for nurses?
DAR matches how many Canadian units teach focus charting. SOAP is acceptable if your EMR template is SOAP. The college cares that the record is timely, factual, and complete, not that you used a particular acronym.
How soon do I have to chart?
As close to the event as the unit allows. High-risk events (falls, PRN for agitation, deterioration, refusal of a critical med) should be in the chart before you go to break. Late entries must be labelled late. Follow your college and employer policy.
Can Scribeberry write nursing notes?
Yes. Use a DAR or narrative template, dictate or record, generate, then edit times and names before you sign. You remain accountable for the entry, including any late-entry rules on your unit.
Templates
