Every guide to nursing notes tells you what to write. Be objective. Be specific. Include the vital signs.

None of them tells you the five properties an entry has to have before it counts as a record at all. Two of those five are exactly where shift documentation fails, and one of them is not what most nurses would guess.

Here are worked examples in narrative, SOAPIE and DAR, the three blank templates, and the rules that decide whether an entry holds up when somebody reads it back a year later.

Key Takeaway: A nursing note records what you observed, what you did, and how the patient responded, across one shift or one event. Federal rules set five properties every entry must have. 42 CFR 482.24 requires that all patient medical record entries be "legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided" [1]. Nurses write in three main formats, narrative, SOAPIE and DAR focus charting, and the format is a unit convention rather than a rule. The note also has to connect to the nursing care plan, which 42 CFR 482.23 requires nursing staff to develop and keep current for each patient, reflecting the patient's goals and the care to be provided [2]. Sully.ai's AI Scribe captures what you describe during the shift and writes it into the format your unit uses.

What a Nursing Note Records

Four things: what you observed, what you did, how the patient responded, and what you escalated.

The third one is where most notes stop short. "Repositioned patient" is half an entry. What happened next is the other half, and it is the difference between a nursing note and a task list.

What Goes in the Note

The shift note is not a transcript of everything that happened. It is the record of anything that changed, anything you did about it, and anything the next nurse needs.

Pick the format your unit uses. The argument about which one is best is the argument everyone has, and it is the least important thing on this page.

The Five Properties Every Entry Must Have

Here is the part no competing page mentions.

42 CFR 482.24(c)(1)[1]:

"All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures."

Legible, complete, dated, timed, authenticated.

Three things follow from that list.

One. Timed is separate from dated, and it is the property nursing fails. A shift note whose entries all carry the same end-of-shift timestamp records when you typed, not when anything happened. Sequence is the whole clinical value of a nursing note. When the question a year later is whether the change was noticed before or after the call was made, the date tells nobody anything.

Two. Complete is measurable, not aspirational. A 2020 study examined completeness and accuracy in nursing assessment across more than 12,000 computerized nursing records at an Italian teaching hospital, treating documentation quality as a proxy for quality of care [3]. Incomplete is a finding somebody can count, not a style preference.

Three. The note has to connect to the care plan. 42 CFR 482.23(b)(4) requires nursing staff to develop and keep current "a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs" [2]. A shift note that lists tasks and never reports against the care plan leaves the plan unevidenced.

A caveat worth stating. Both of those sections are Medicare Conditions of Participation for hospitals. They do not directly bind a school clinic, a private duty shift or a doctor's office. What they are is the clearest federal statement of what an entry has to be, and surveyors, malpractice reviewers and employers all reason from the same five properties.

Narrative, SOAPIE or DAR

Three formats, and the honest answer is that your unit has already decided.

Narrative is chronological free text with a timestamp on each entry. Best for end of shift summaries and for events, because a sequence is exactly what it is good at. Its weakness is that nothing in the structure forces you to say whether an intervention worked.

SOAPIE is SOAP plus the two letters nursing actually needs. Subjective, Objective, Assessment, Plan, Intervention, Evaluation. If you already know SOAP, SOAPIE is that with what you did and whether it helped bolted on the end.

DAR focus charting names one focus, then Data, Action, Response. It is the best of the three for a single event, because the Response line is not optional.

All three satisfy the five properties, or all three fail them, depending on how you fill them in. Open nursing curricula teach sample documentation in each [4].

The Nursing Note Templates

Three blocks. Each one is complete as written, so you can paste it straight into a chart.

The Narrative Shift Note Template

NARRATIVE NOTE

• Patient, date, shift:(and the unit)

• HHMM(time of the observation, not the time you are writing) (what you observed, in objective terms)

• HHMM(what you did, including who you notified and when)

• HHMM(how the patient responded, reassessment findings)

• HHMM(handover items for the next shift)

• Signature and credentials: (the person who provided or evaluated the care)

One line matters more than the rest. Each entry gets the time the thing happened, not the time you sat down. A full narrative shift note template is also available as a page you can open directly.

The SOAPIE Template

SOAPIE NOTE

• S, Subjective:"(what the patient said, in their words)"

• O, Objective:(vital signs, measurements, what you observed and assessed)

• A, Assessment: (your nursing judgment about what is going on, not a medical diagnosis)

• P, Plan:(what you intend to do, tied to the care plan)

• I, Intervention: (what you actually did, with the time)

• E, Evaluation:(whether it worked, with the reassessment time and finding)

The last two letters are the point. A SOAPIE note template without a filled-in E is a SOAP note with two empty boxes.

The DAR Focus Charting Template

FOCUS NOTE

• Focus: (the one problem, symptom or event this note is about)

• D, Data:(what you observed and measured, with the time)

• A, Action:(what you did, who you notified, when)

• R, Response:(how the patient responded, with the reassessment time)

• Signature and credentials: (and the time you signed, if different from the events above)

The Response field is why DAR focus charting exists. If you leave it blank the note is visibly unfinished, which is the design working.

Where Sully.ai Fits in Shift Documentation

Start with the size of the problem, from a study rather than a brochure. A 2025 paper in Healthcare Informatics Research states that nursing documentation consumes approximately 30 percent of nurses' professional time, and tested a generative AI documentation system against traditional electronic nursing records with forty nurses [5].

Thirty percent of a twelve hour shift is nearly four hours.

Most of that gets spent at the end, in a batch, reconstructed from memory and from notes on a folded piece of paper. That is exactly where the times stop being real and the response lines go missing, which are two of the five properties.

Sully.ai's AI Scribe captures what you describe during the shift and writes it into the format your unit uses, so the time attaches to the observation rather than to the moment you finally sat down. It runs on a single integration across Epic, Cerner, Meditech and Athenahealth.

Now the boundary, and on a nursing floor it is a legal one rather than a preference.

That same study did not assume the AI-suggested entries were correct. It evaluated their accuracy [5]. Take the same posture. A scribe drafts. The nurse verifies. The nurse authenticates.

42 CFR 482.24 requires authentication by "the person responsible for providing or evaluating the service provided" [1]. That is you. It cannot be delegated to software, and signing an entry you have not read is the one failure mode a scribe makes easier rather than harder. Read the response lines before you sign, every time.

Sully operates across 5,000+ providers, has delivered 50M+ hours of AI work, and prices each AI role 80 to 90 percent below the human equivalent [6].

Nursing Notes Examples Written Out

Three examples. The first two are the same shift written two ways, so the formats can be compared directly rather than across unrelated patients.

An End of Shift Narrative Note

68 year old, day two of admission, community-acquired pneumonia. Day shift, 0700 to 1900.

0715 Patient awake, sitting upright. Head-to-toe assessment completed. Reports "I can get a breath now, yesterday I couldn't." Temp 37.8, HR 92, RR 22, BP 128/74, SpO2 91% on 2L nasal cannula. Productive cough, sputum thick and rust colored.

0740 Ambulated to bathroom with one assist, SpO2 dropped to 87% on exertion, recovered to 92% after two minutes seated. Patient reported no dizziness.

0745 Notified Dr. Adeyemi of exertional desaturation. Order received to increase to 3L and obtain ambulatory oximetry with physiotherapy.

0900 Oxygen increased to 3L per order. SpO2 94% at rest.

1120Physiotherapy session completed. Ambulated 20 meters with a frame, SpO2 nadir 90% on 3L, recovered to 94% within 60 seconds. Patient tolerated without distress.

1400 Temp 37.2, HR 84, RR 18, BP 124/70, SpO2 95% on 3L. Cough less frequent, sputum thinner and paler than this morning.

1830 Handover to night shift: currently 3L, target sats 92 to 96%, ambulatory oximetry recorded and in chart, physiotherapy booked 1000 tomorrow. Family visiting, updated by Dr. Adeyemi at 1600.

Signature: R. Mensah, RN.

Every entry carries its own time. That is the single thing separating this from a note written at 1845 that says "patient ambulated, desaturated, oxygen increased, tolerated well."

The Same Shift in SOAPIE

S, Subjective: "I can get a breath now, yesterday I couldn't." Denies chest pain and dizziness on exertion.

O, Objective:0715 temp 37.8, HR 92, RR 22, BP 128/74, SpO2 91% on 2L. Productive cough, sputum thick and rust colored. 0740 SpO2 87% on ambulation to bathroom, recovered to 92% seated within two minutes. 1400 temp 37.2, HR 84, RR 18, SpO2 95% on 3L, sputum thinner and paler.

A, Assessment:Respiratory status improving at rest but with exertional desaturation not present in yesterday's documentation. Secretions loosening. Oxygen requirement increased today rather than decreased, which is the finding worth flagging at handover.

P, Plan: Maintain target saturations 92 to 96%. Continue physiotherapy. Monitor oxygen requirement for a downward trend over the next 24 hours.

I, Intervention:0745 notified Dr. Adeyemi of exertional desaturation, order received. 0900 oxygen increased to 3L. 1120 physiotherapy session supported, ambulatory oximetry recorded.

E, Evaluation:Post-intervention SpO2 94% at rest and nadir 90% on ambulation with 60 second recovery, compared with 87% and a two minute recovery pre-intervention. Exertional tolerance improved within the shift.

Same shift, same facts. What the format added is the last paragraph. The narrative version could have ended at "oxygen increased" and nothing in its structure would have complained.

A Focus Note for a Single Event

Unwitnessed falls are the highest-stakes entry a nurse writes, and the one where all five properties get tested at once.

FOCUS NOTE

Focus:Unwitnessed fall.

D, Data: 0312 Patient found sitting on floor beside bed on entering room in response to call bell. Patient alert, oriented to person, place and time. States "I was trying to get to the bathroom." No loss of consciousness reported by patient. No visible head injury. Small skin tear 2 cm to left forearm, minimal bleeding. Reports pain 3 out of 10 left hip, no deformity, no shortening, no external rotation. Able to move all four limbs on command. Vital signs 0315: BP 132/78, HR 88, RR 18, temp 36.9, SpO2 96% on room air. Bed in low position, call bell within reach, non-slip socks on, floor dry.

A, Action: 0316 Assisted back to bed with two staff using a full assist. Neurological observations commenced per falls protocol. 0320 Dr. Chen notified, attended at 0335. 0340 Skin tear cleaned and dressed. Falls risk reassessed, score increased from 8 to 12. Bed alarm activated. 0350 Daughter notified by telephone, per patient's request. Incident report submitted.

R, Response: Patient settled and comfortable in bed by 0355, reports hip pain 2 out of 10. Neurological observations unchanged at 0400 and 0500. Hip x-ray ordered by Dr. Chen at 0345, performed 0520, no fracture reported. Patient slept from 0530. No further falls this shift.

Signature: R. Mensah, RN, 0610.

Note what is not in there. No cause, no mechanism, no "appears to have lost balance." The fall was unwitnessed, so the only honest word is found. Everything after that is an objective finding, a named action with a time, or a documented response.

What Gets a Nursing Note Questioned

A Time That Is Just the Time You Wrote It

Eight hours of care carrying one timestamp is the most common defect in shift documentation, and it fails a named federal property rather than a stylistic preference [1].

Time each observation to when it happened. If you are writing something up hours later, label it as a late entry rather than back-dating it to when you wish you had written it. Your employer's policy governs how that is recorded, which is what the regulation itself defers to.

Interventions With No Response Line

"Repositioned patient." "Analgesia administered." "Patient educated on incentive spirometry."

All three are half-entries. What happened next is the half that matters, and it is the half a reviewer looks for. DAR is built to force it, SOAPIE has a dedicated letter for it, and narrative notes have to remember [4].

The test: read your entry and ask whether anyone could tell, from the note alone, if the thing you did worked.

Book a demo and bring last night's shift notes. The question worth asking is how many different timestamps are on them.

FAQ

Q: How do you write a nursing note? Record what you observed, what you did, how the patient responded, and what you escalated, in the format your unit uses. Every entry has to be legible, complete, dated, timed and authenticated by the person who provided or evaluated the service [1]. There are three worked examples on this page in narrative, SOAPIE and DAR focus formats.

Q: What are some examples of nursing documentation? This page has three written out in full: an end of shift narrative note for a patient with pneumonia, the same shift in SOAPIE, and a DAR focus note for an unwitnessed fall. Each has its blank template above it.

Q: What is the difference between narrative, SOAPIE and DAR charting? Narrative is chronological time-stamped free text, good for shifts and events. SOAPIE adds Intervention and Evaluation to SOAP, so the note has to say what you did and whether it worked. DAR names one focus and records Data, Action and Response, which makes the response line mandatory. All three can satisfy the same requirements, so the format is a unit convention rather than a rule.

Q: How do you correct an error in a nursing note? Follow your employer's policy. That is not a dodge, it is what the federal rule does: entries must be authenticated "consistent with hospital policies and procedures" [1]. The general principle across policies is that a correction leaves the original entry readable rather than obliterated, and that a late entry is labeled as a late entry rather than back-timed. Check your own policy for the mechanics, and do not take a blog as your source for this one.

Q: Do you have a free nursing note template? Yes. Blank narrative, SOAPIE and DAR templates are all on this page as copy-paste blocks, with three worked examples. Sully.ai's AI Scribe can also capture what you describe during the shift and write it into whichever format your unit uses.

Sources

[1] Office of the Federal Register — 42 CFR 482.24, Condition of participation, Medical records[2] Office of the Federal Register — 42 CFR 482.23, Condition of participation, Nursing services[3] International Journal of Environmental Research and Public Health — Quality of Care, Ecological Study for the Evaluation of Completeness and Accuracy in Nursing Assessment [4] Wisconsin Technical College System, Nursing Skills 2e — Sample Documentation [5] Healthcare Informatics Research — Generative AI-Based Nursing Diagnosis and Documentation Recommendation Using Virtual Patient Electronic Nursing Record Data [6] Sully.ai— The AI Workforce for Healthcare