8 Essential Nursing Documentation Sample Templates for 2026

In the fast-paced world of healthcare, clear and efficient nursing documentation is not just a task—it's the backbone of patient safety, legal compliance, and care continuity. Poor charting can lead to medical errors and miscommunication, while excellent notes ensure every member of the care team is aligned and informed. However, mastering the various formats required for different clinical scenarios can be a constant challenge for new and veteran nurses alike. Without a solid foundation and clear examples, nurses risk creating notes that are incomplete, legally vulnerable, or fail to communicate the full clinical picture. This can have serious repercussions, from delayed patient care to increased organizational liability.

This guide simplifies the process by providing concrete examples and strategic breakdowns. We'll explore a variety of nursing documentation sample templates, from the universally recognized SOAP note to specialized formats for telehealth and incident reporting. Each example comes with actionable takeaways and tips for adapting them to modern tools like Electronic Health Records (EHRs) and voice-to-text assistants. By breaking down each format into its core components, we aim to demystify the charting process and empower you with the confidence to document accurately in any situation.

Our goal is to help you create documentation that is both comprehensive and efficient, reclaiming valuable time for direct patient care. To further streamline your documentation, exploring various structured approaches and even finding actionable sample templates can be highly beneficial. Let's dive into the examples that will help you chart with confidence and precision.

1. SOAP Note (Subjective, Objective, Assessment, Plan)

The SOAP note is one of the most widely used methods for clinical documentation, offering a clear, logical framework that organizes patient information into four distinct categories. This structured format helps nurses and other healthcare providers communicate effectively, ensuring all critical aspects of a patient encounter are recorded systematically. The logical flow from subjective complaints to a concrete plan makes it an indispensable nursing documentation sample for various clinical settings. It promotes critical thinking by forcing the clinician to connect the patient's story with objective data before forming a plan.

This method, developed by Dr. Larry Weed, structures clinical reasoning and is a cornerstone of the Problem-Oriented Medical Record (POMR). It’s especially effective in primary care for routine visits, urgent care for rapid assessments, and telemedicine for organizing remote consultation details. The SOAP format is valuable because it creates a shared mental model among providers, ensuring that anyone reading the note can quickly grasp the patient's status and the rationale behind the care plan. Its structured nature also makes it highly compatible with modern EHR systems, which often feature built-in SOAP templates.

SOAP Note Breakdown and Example

Let's look at a nursing documentation sample using the SOAP format for a patient with a respiratory complaint.

• S (Subjective): Patient states, "I've had a bad cough for three days and feel tired." Reports chest congestion and a mild headache. Denies fever or shortness of breath. Also mentions, "It feels like my chest is tight when I take a deep breath." He has been using over-the-counter cough syrup with minimal relief.
• O (Objective): Vitals: T 99.1°F, P 88, R 18, BP 124/78, SpO2 98% on room air. Lungs clear to auscultation bilaterally, but with scattered rhonchi in upper lobes. Non-productive cough noted during examination. Patient appears fatigued but is in no acute distress. Nasal mucosa is slightly inflamed.
• A (Assessment): Based on the subjective reports and objective findings, the primary nursing diagnosis is Ineffective Airway Clearance related to retained secretions and inflammation. The patient's symptoms are consistent with an upper respiratory tract infection, likely viral in nature.
• P (Plan): Encourage fluid intake to 2L/day to thin secretions. Instruct patient on deep breathing and coughing exercises to perform every two hours while awake. Will continue to monitor vital signs and lung sounds every 4 hours. Recommend follow-up with the primary care provider if symptoms do not improve in 48-72 hours or if shortness of breath develops. Patient verbalized understanding of the plan.

Actionable Tips for Implementation

To make your SOAP notes more effective, focus on clarity and precision. Use direct quotes for subjective information when possible to capture the patient's own words. In the objective section, stick to measurable, observable data—avoid interpretations. Your assessment should clearly connect the subjective and objective data to a clinical conclusion or nursing diagnosis. Finally, ensure your plan is specific, outlining clear actions, patient education, and follow-up instructions. EMR templates can standardize this process, promoting consistency across your team. Regularly review your SOAP notes to ensure they tell a coherent clinical story.

2. Nursing Care Plan Documentation

A Nursing Care Plan is a comprehensive document that serves as a roadmap for patient care, detailing nursing diagnoses, expected outcomes, interventions, and evaluations. This structured approach ensures individualized, holistic care by systematically addressing a patient's specific health problems. It provides a clear and actionable nursing documentation sample that guides the entire healthcare team toward common goals, making it essential for managing complex patient needs. It's a dynamic document that evolves with the patient's condition, promoting proactive rather than reactive care.

This method is standardized using frameworks like NANDA International for diagnoses, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC). It is most effective in hospital inpatient units, long-term care facilities, and home health settings where patients require ongoing, coordinated care to manage complex or chronic conditions. The care plan acts as a central communication hub, ensuring that all disciplines—from nursing to physical therapy to social work—are working cohesively towards the same patient-centered goals. This level of coordination is critical for preventing fragmented care and improving patient outcomes.

Nursing Care Plan Breakdown and Example

Let's review a nursing documentation sample using a care plan format for a post-operative patient at risk for infection.

• Nursing Diagnosis: Risk for Infection related to surgical incision, secondary to compromised skin integrity.
• Expected Outcome: Patient will remain free of signs and symptoms of infection (redness, swelling, purulent drainage, fever) throughout the post-operative period. The surgical wound will show signs of normal healing by discharge, evidenced by well-approximated edges and diminishing inflammation.
• Interventions:
  1. Assess the surgical incision for signs of infection (redness, warmth, drainage, increasing pain) every 4 hours.
  2. Monitor vital signs, especially temperature, every 4 hours. Report any temperature greater than 100.4°F to the provider.
  3. Perform sterile dressing changes as ordered by the surgeon, documenting the appearance of the wound and any drainage.
  4. Educate the patient and family on proper hand hygiene and signs of infection to report immediately.
  5. Ensure adequate patient nutrition and hydration to support wound healing.
• Evaluation: Patient's surgical site remains clean, dry, and intact with no signs of infection. Edges are well-approximated. Patient verbalizes understanding of hand hygiene and when to notify the nurse. The plan will continue to be monitored, and the evaluation will be updated every shift to reflect the patient's progress toward the outcome.

Actionable Tips for Implementation

To create effective care plans, use standardized NANDA-I terminology within your EMR to ensure consistency and clear communication. Make outcomes Specific, Measurable, Achievable, Relevant, and Time-bound (SMART). For each intervention, document the rationale to support evidence-based practice and clarify its purpose. Regularly update the care plan at each patient interaction to reflect progress or changes, ensuring it remains a dynamic and relevant tool for guiding care. Involve the patient and their family in the planning process to promote engagement and adherence.

3. Shift Handoff and SBAR Communication Template

The SBAR (Situation, Background, Assessment, Recommendation) template is a powerful communication tool designed to standardize information exchange between healthcare providers. Originally developed for high-risk industries like aviation, it was adapted by organizations like Kaiser Permanente to enhance patient safety. This structured format provides a concise and predictable framework, making it an essential nursing documentation sample for critical moments like shift handoffs, patient transfers, or when escalating concerns to a physician. Its simplicity is its strength, cutting through extraneous detail to focus on what is immediately important.

This method is highly effective for reducing miscommunication errors that can lead to adverse patient outcomes. It is particularly valuable in fast-paced environments like emergency departments, surgical units, and intensive care, ensuring that vital information is not missed during care transitions. By creating a shared language for urgent communication, SBAR helps flatten hierarchies, empowering nurses to present information to physicians in a clear, confident, and actionable manner. This structure minimizes the risk of critical details being overlooked in the heat of the moment.

SBAR Breakdown and Example

Let's look at a nursing documentation sample using the SBAR format for escalating a patient's worsening condition to a physician.

• S (Situation): "Dr. Smith, this is Nurse Johnson on the Med-Surg unit. I am calling about Mr. Davis in room 402, who is experiencing new-onset chest pain and shortness of breath."
• B (Background): "He is a 68-year-old male, two days post-op from a knee replacement. He has a history of hypertension but no prior cardiac issues. His morning vitals were stable. He received his last dose of Lovenox at 0900."
• A (Assessment): "His current vitals are BP 160/95, HR 110, RR 22, SpO2 92% on room air. He is pale and diaphoretic. His chest pain is a 7/10, described as a 'crushing' sensation. I believe he may be having a cardiac event, possibly a pulmonary embolism or myocardial infarction."
• P (Plan/Recommendation): "I recommend you come see the patient immediately. In the meantime, should I start him on 2L of oxygen via nasal cannula and get a stat ECG and troponin level?"

Actionable Tips for Implementation

To implement SBAR effectively, ensure all staff are trained on the format and understand its importance in patient safety. During the Background, provide only the most relevant history to keep the handoff concise (under 30 seconds is a good goal). Your Assessment should state the immediate clinical problem as you see it. Finally, your Recommendation must be clear and direct, proposing specific actions or asking for orders. Documenting the handoff completion in the EMR with a timestamp is crucial for accountability. To further explore handoff strategies, you can find a comprehensive nursing handoff report template to guide your process.

4. Electronic Health Record (EHR) Progress Notes with Structured Data Capture

EHR progress notes with structured data capture represent a modern, hybrid approach to clinical documentation. This method combines traditional free-text narrative sections with structured data fields like checkboxes, dropdown menus, and automatically populated metrics. This integration enhances both the quality of documentation and data interoperability, creating a comprehensive and standardized patient record. The structure balances the need for detailed clinical narrative with the efficiency of standardized, machine-readable data, which can then be used for quality reporting, research, and clinical decision support.

This method, championed by EHR vendors like Epic Systems and Cerner, is essential in settings requiring high levels of data analysis and care coordination, such as primary care medical homes and specialty practices tracking condition-specific outcomes. It’s also ideal for multi-location health systems aiming to standardize documentation across all sites. By capturing key data points in a structured format, organizations can more easily track patient populations, monitor adherence to clinical guidelines, and identify trends that might be missed in narrative notes alone.

EHR Note Breakdown and Example

Here is a nursing documentation sample from an EHR template for a patient with hypertension, combining narrative and structured fields.

• Chief Complaint: Follow-up for hypertension management.
• History of Present Illness (Narrative): Patient reports good adherence to Lisinopril 10mg daily. Denies chest pain, shortness of breath, or dizziness. Notes occasional mild headaches in the morning, which he attributes to stress. States he is trying to reduce salt in his diet.
• Review of Systems (Structured Checkboxes):
  • Constitutional: [✓] No fever, [ ] Weight loss, [ ] Fatigue
  • Cardiovascular: [✓] No chest pain, [✓] No palpitations, [ ] Edema
  • Neurological: [✓] Headache (as noted above), [ ] Dizziness, [ ] Numbness
• Vital Signs (Structured Data Fields):
  • BP: 132/84 mmHg (auto-populated from device)
  • HR: 76 bpm
  • Temp: 98.4°F
• Assessment: Hypertension, controlled. Morning headaches, likely unrelated to BP at this time, possibly tension-related.
• Plan (Structured & Narrative): Continue current medication regimen. Educate patient on monitoring BP at home twice weekly and keeping a log. Recommended Tylenol for headaches and stress management techniques. Provided a handout on the DASH diet. Return to clinic in 3 months for re-evaluation.

Actionable Tips for Implementation

To maximize the benefits of EHR progress notes, work with your EHR vendor or IT department to customize smart templates tailored to your specialty. Utilize voice-AI tools like Simbie to populate both narrative and structured fields from patient conversations, saving significant time. Establish clear practice-wide standards for template use to ensure consistency. Regularly review and update templates to prevent "note bloat" and discourage the overuse of copy-paste, which can introduce errors and outdated information into the patient record.

5. Admission, Transfer, Discharge (ATD) Documentation

Admission, Transfer, and Discharge (ATD) documentation provides a comprehensive and standardized record for patients as they move between different care settings. These crucial notes ensure that vital information about a patient's status, medications, and ongoing care plan is clearly communicated. Proper ATD documentation is a cornerstone of patient safety, directly impacting continuity of care and helping to prevent readmissions. These documents serve as a legal and clinical "handshake" between different levels or locations of care.

This form of nursing documentation sample is essential for meeting standards set by organizations like The Joint Commission and CMS. It is used during hospital admissions from the emergency department, transfers from an ICU to a medical-surgical floor, and upon discharge to home or a skilled nursing facility. Incomplete or inaccurate ATD documentation is a leading cause of post-discharge adverse events, making mastery of this format a high-priority skill for all nurses.

ATD Documentation Breakdown and Example

Let's review a nursing documentation sample for a patient being discharged home after treatment for pneumonia.

• Admission/Transfer Summary: Patient admitted on [Date] with community-acquired pneumonia. Treated with IV Levaquin, then transitioned to oral. VSS and afebrile for 48 hours. Lungs clear to auscultation. Tolerating diet and ambulating independently. Required 2L O2 via NC initially, weaned to room air on day 2.
• Discharge Condition: Patient is alert and oriented x4. Vitals stable: T 98.4°F, P 76, R 16, BP 130/82, SpO2 97% on room air. Reports feeling "much better" and denies shortness of breath or chest pain. Ambulating without assistance.
• Discharge Instructions/Plan: Complete 5-day course of oral Levaquin 500mg daily. Follow up with PCP, Dr. Smith, in 7-10 days (appointment scheduled for [Date] at [Time]). Increase fluid intake and get adequate rest. No driving while on this medication.
• Patient Education: Patient and spouse educated on medication schedule, potential side effects (tendonitis, GI upset), and signs of worsening condition (e.g., fever, increased cough, difficulty breathing). Patient verbalized understanding and demonstrated the "teach-back" method regarding when to call the doctor or seek emergency care. Provided with written instructions.

Actionable Tips for Implementation

To improve your ATD documentation, focus on clarity and completeness. Always perform a thorough medication reconciliation at every transition point to prevent errors. Use the teach-back method to confirm the patient and their family understand all discharge instructions, and document their response. Provide clear, written instructions, including follow-up appointment details and warning signs that require immediate medical attention. Involve social workers or case managers early to address any barriers to a safe discharge, such as transportation or home support. For a more detailed guide on creating admission notes, you can find a helpful nursing admission note example here.

6. Medication Administration Record (MAR) with Documentation Integration

The Medication Administration Record (MAR) is a fundamental legal document in healthcare, providing a precise and chronological log of every medication given to a patient. This essential record tracks the drug name, dose, route, and time of administration, along with the signature of the nurse who administered it. Modern electronic MARs (eMARs) are a cornerstone of patient safety, integrating with EMRs and barcode scanning to prevent critical medication errors. It is not just a task list, but a vital piece of the patient's legal medical record.

This comprehensive nursing documentation sample is non-negotiable in settings like hospital inpatient units, long-term care facilities, and infusion centers. The integration of technology, guided by standards from The Joint Commission and the Institute for Safe Medication Practices (ISMP), has transformed the MAR from a simple chart into a dynamic safety tool that ensures the "Five Rights" of medication administration are met: right patient, right drug, right dose, right route, and right time. An accurate MAR is also crucial for communication between shifts and for medication reconciliation during patient transfers.

MAR Breakdown and Example

Let's review a nursing documentation sample from an eMAR for a post-operative patient.

• Medication: Lisinopril 10 mg Tablet
• Route: Oral (PO)
• Frequency: Daily
• Time Due: 0900
• Administration Log:
  • 0905: Lisinopril 10 mg PO administered. Patient tolerated well. BP pre-administration: 148/92. BP post-administration (1000): 136/84. Patient educated to call for assistance before getting out of bed. — J. Doe, RN
  • 0900 (Next Day): Patient refused medication, stating, "I feel dizzy this morning." Refusal documented. Provider Dr. Smith notified at 0910 via secure message. Awaiting new orders. Vitals at 0900: BP 128/78, P 72. — J. Doe, RN

Actionable Tips for Implementation

To maximize the effectiveness and safety of your MAR documentation, always document medication administration immediately after giving the dose, not before. Integrate barcode scanning at every point of care to verify patient identity and medication details, which drastically reduces human error. Establish a clear, standardized protocol for documenting refused, held, or partial doses, ensuring the clinical reason and provider notification are always included. For PRN (as-needed) medications, always document the reason for administration and the patient's response to evaluate its effectiveness. For additional resources, you can explore various medication charting templates to streamline your workflow and ensure compliance.

7. Tele-Health and Remote Patient Monitoring Documentation

Tele-health documentation is a specialized format designed for virtual patient encounters, including video calls, phone consultations, and remote patient monitoring (RPM). This format is crucial for capturing the unique aspects of virtual care, such as the technology used, patient location, and consent for a non-physical examination. A proper tele-health nursing documentation sample ensures continuity of care while meeting specific regulatory and billing requirements for remote services. It must paint a clear picture of an encounter that lacks the traditional hands-on assessment components.

This documentation method has become essential with the rise of virtual care platforms and RPM programs for chronic disease management. It provides a clear record of the virtual interaction, protecting both the patient and the provider while ensuring accurate reimbursement for services rendered outside a traditional clinical setting. Effective tele-health notes must clearly justify the medical necessity of the virtual visit and demonstrate the same level of clinical decision-making as an in-person encounter.

Tele-Health Note Breakdown and Example

Here is a nursing documentation sample for a tele-health follow-up visit with a patient managing hypertension.

• Pre-Encounter/Subjective: Patient completed an automated pre-visit intake. States, "I've been checking my blood pressure at home like you asked, and the readings seem a little high this week." Reports taking medications as prescribed and denies dizziness, headache, or chest pain. Confirms having his medication bottles available for review.
• O (Objective): Synchronous video visit conducted via a HIPAA-compliant platform (e.g., Doxy.me). Patient located at home in [City, State]. Patient provided verbal consent for the virtual visit and confirmed their identity. Patient-reported home blood pressure readings for the last 3 days average 145/92 mmHg. Remote monitoring device data confirms an average reading of 144/90 mmHg over the last 72 hours. Patient appeared comfortable and in no distress via video.
• A (Assessment): Based on remote data and patient report, the primary issue is Hypertension not at goal. Patient demonstrates good understanding of medication regimen but requires adjustment to achieve target blood pressure. No signs of acute complications.
• P (Plan): Provider consulted; Lisinopril increased to 20mg daily. Educated patient on the new dosage and potential side effects. Instructed patient to continue daily home BP monitoring and report back in one week. Will schedule a follow-up video visit in two weeks to reassess. Sent an after-visit summary to the patient's portal with updated medication information.

Actionable Tips for Implementation

To optimize tele-health documentation, always begin by documenting patient consent for the virtual visit and verifying their location. Clearly state the technology platform used (e.g., "secure video link"). When possible, integrate data from remote monitoring devices directly into the EMR to support patient-reported information. Establish and document clear protocols for when a patient's condition requires escalation to an in-person visit. Using automated intake tools can streamline symptom collection before the virtual encounter begins, allowing more time for clinical assessment and patient education during the call.

8. Incident Reports and Occurrence Documentation

Incident reports, also known as occurrence reports, are essential documents for recording any event that deviates from the standard of care. This includes patient falls, medication errors, or equipment failures. This form of documentation is critical for patient safety, quality improvement, and risk management, providing a factual, objective account of unexpected events. Unlike clinical notes, incident reports are often confidential internal documents used for analysis and process improvement, not for assigning blame.

This documentation is a cornerstone of a safe healthcare environment, mandated by regulatory bodies like The Joint Commission. It is especially vital in high-acuity settings like hospitals and long-term care facilities where risks are higher, but it is equally important in outpatient clinics to track trends and prevent future harm. The goal of an incident report is to learn from mistakes and near misses to build stronger, safer systems of care.

Incident Report Breakdown and Example

Let's review a nursing documentation sample for an unwitnessed patient fall.

• Event Description (Objective & Factual): At 07:30, upon entering room 204, the patient was found on the floor next to the bed. Patient stated, "I was trying to get to the bathroom and my legs gave out." Bed was in the lowest position with two side rails up. Call light was within reach on the bedside table. Floor was dry and free of clutter.
• Initial Findings/Assessment: Patient alert and oriented x4. Denies head, neck, or back pain. Reports pain to the left hip, rated 4/10. Full range of motion in all extremities noted, with guarding of the left hip. No visible signs of trauma, such as bruising, swelling, or lacerations, were observed on initial inspection.
• Immediate Actions Taken: Assisted patient back to bed with the help of one staff member using a gait belt. Vitals signs taken: BP 138/84, P 92, R 18, SpO2 97% on room air. Dr. Smith notified of the event and patient's status at 07:45. A full set of post-fall neurological checks was initiated.
• Plan/Follow-Up: Per Dr. Smith's new orders, will obtain a stat X-ray of the left hip. Continue to monitor neurological and vital signs every hour for the next 4 hours, then every 4 hours for 24 hours. Implemented fall precautions, including a bed alarm and ensuring non-skid socks are worn at all times. Physical therapy consult ordered to reassess mobility.

Actionable Tips for Implementation

When writing an incident report, your primary goal is to be objective and factual. Never include opinions, blame, or assumptions. State exactly what you saw and heard, using direct quotes from the patient when possible. Document all immediate actions taken, including who was notified and when. Ensure the report is completed promptly, typically within 24 hours of the event. Separately, document the clinical assessment and interventions in the patient's medical record, but do not reference the incident report in the chart, as it is a quality improvement tool, not part of the legal medical record.

8-Item Nursing Documentation Sample Comparison

From Templates to Technology: Automating Your Documentation Workflow

We've explored a wide array of nursing documentation sample templates, from the classic SOAP note to specialized forms for admissions, tele-health, and incident reporting. Each example serves as a critical blueprint, demonstrating how structured, clear, and comprehensive charting forms the bedrock of patient safety, legal protection, and continuity of care. Mastering these formats is no longer just about compliance; it's about communicating a precise clinical story that informs every decision. The ability to effectively translate a patient encounter into a well-structured note is a hallmark of an expert clinician.

The core takeaway from these examples is the power of consistency and detail. Whether you are using an SBAR for a shift handoff or completing a MAR, the principles remain the same: be objective, be thorough, and be timely. A well-crafted nursing documentation sample isn't just a record of events; it's a dynamic tool that protects your license, validates care delivery for billing, and ultimately ensures your patients receive the best possible outcomes. By internalizing the structure and strategic language of these templates, you build a powerful professional habit that reduces errors and elevates the quality of your practice. This skill is as crucial as any clinical procedure you perform.

Actionable Next Steps: From Theory to Practice

Moving forward, the goal is to transform these static examples into a dynamic, efficient workflow. Don't just file these templates away. Start actively integrating their principles into your daily charting. True mastery comes from consistent application and a commitment to continuous improvement in your documentation skills.

• Review and Refine: Pick one area of your current documentation that feels weak or time-consuming. Compare it against the relevant nursing documentation sample from this guide and identify three specific improvements you can make this week. For example, you could focus on making your care plan goals more measurable or ensuring your SBAR reports are consistently concise.
• Embrace Technology: Begin exploring how technology can bridge the gap between template theory and practical application. Look into your EMR’s built-in smart phrases or template builders. To genuinely automate your documentation workflow and save valuable time, leveraging the best speech to text software can be a transformative step for healthcare professionals. This technology can help capture narrative notes more quickly, allowing you to focus on structure and content.
• Champion Change: Share these examples with your colleagues. A team-wide commitment to documentation excellence creates a culture of safety and precision that benefits the entire unit and, most importantly, every patient you serve. Consider leading a brief in-service or peer-review session focused on one of these documentation types.

The Future is Efficient, Accurate, and Automated

Ultimately, the journey from novice to expert in clinical documentation involves moving beyond simple memorization toward strategic implementation. The examples provided are your foundation, but the future of healthcare documentation is one where technology works alongside you. By combining proven documentation structures with intelligent automation tools, you can reclaim valuable time, reduce the risk of burnout, and dedicate more energy to hands-on patient care. This strategic blend of strong fundamentals and smart technology is the key to a more sustainable and rewarding nursing career. The goal is not to replace clinical judgment, but to augment it, freeing you to focus on what matters most—your patients.

Ready to see how AI can transform your documentation workflow? Simbie AI uses clinically-trained voice agents to automate patient intake, medication reconciliation, and follow-ups, structuring the data directly into your EMR. Discover how you can reduce administrative burdens and focus on patient care by visiting Simbie AI to learn more.