A nursing note is the record of your shift: what you assessed, the vital signs, what you did and when, how the patient responded, who you called, what you taught, and what the next nurse needs. Copy the free template, see a night shift with a low blood sugar and a post-op day 2 that went to plan, and check what goes in each part.
Blank nursing note template
FreeNURSING NOTE Patient: [Name] Date of birth: [Date] Ward and bed: [Unit name, room, bed] Shift: [Date, start and end times] Time written: [Time of this entry; label it a late entry if written after the shift] Admitted for: [Reason for admission, and hospital day or post-op day] Allergies: [Allergy and reaction, or no known allergies] Code status and precautions: [Code status, isolation, fall or seizure precautions] Nurse: [Name, credentials] SHIFT SUMMARY [Better, the same, or worse than at the start of the shift; the main event, if any; and whether the plan changed] ASSESSMENT Done: [Full system assessment and its time, then each system you rechecked and when] Neuro and cognition: [Alertness and orientation, compared with the patient's usual] Cardiovascular: [Pulse, perfusion, edema, clot prevention] Respiratory: [Breathing, breath sounds, room air or oxygen device and flow] GI and nutrition: [Diet, how much was eaten, nausea, last bowel movement] GU: [Voiding or catheter, urine color] Skin and wounds: [Pressure areas checked, incisions, dressings, drains] Pain: [Site, score with the scale named, and the patient's goal] Mobility and safety: [Activity, aids, assistance, fall risk, and the precautions in place] Mood and family: [Sleep, mood, worries, visitors] Lines and devices: [IV site and day, infusions and rates, catheters] Intake and output: [By mouth and IV, urine and other losses, in mL for the shift] VITAL SIGNS [Time]: [T, HR, BP, RR, SpO2 on room air or with oxygen device and flow] [Time]: [Extra sets after an event, a new medication, or a change] INTERVENTIONS AND RESPONSE [Time]: [What you did; drug, dose, and route for any medication] Response at [time]: [What changed, measured the same way as before] [Time]: [Next action] Response at [time]: [Result] COMMUNICATION WITH THE PROVIDER [Time]: [Name and role, and how: phone, page, secure message, or on rounds] Reported: [The findings you gave, in SBAR order] Orders and advice: [Each order, read back and confirmed, or no new orders] Follow-up: [When you updated them again, or why no call was needed] PATIENT AND FAMILY EDUCATION Taught: [Topic, to whom, and how: talk, handout, or demonstration] Understanding: [Teach-back or return demonstration, in the patient's words] Shared with family: [Who, when, and what, with the patient's agreement] Still to teach: [What is left, and when] PLAN FOR THE NEXT SHIFT Due: [Medications, checks, tests, and dressing changes, with times] Pending: [Results, consults, and replies not yet back] Call if: [The finding or number that should prompt a call, and to whom] Goals: [What the patient is working toward on the next shift] Signed: [Nurse name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Medical ward, night shift 19:00 to 07:00, hospital day 3
76-year-old man, hospital day 3 of an admission for acute kidney injury after 4 days of vomiting and diarrhea. Type 2 diabetes on insulin glargine 26 units at bedtime; his metformin has been held since admission. No known drug allergies. Full code. Overnight: low blood sugar at 03:10 with new confusion, treated with IV dextrose, and back to his usual self by 03:30. Night hospitalist called; IV fluid and insulin orders changed. Otherwise improving: no vomiting since day 2, good urine output. Entry written at 06:55.
Full assessment at 20:00; focused neuro and glucose checks from 03:10. Neuro: at 20:00, alert and oriented to person, place, and time, which his daughter says is his usual; at 03:10, see below. Cardiovascular: pulse regular, capillary refill under 3 seconds, no edema. Respiratory: clear on both sides, room air. GI and nutrition: diabetic diet; ate about 20% of supper, by the evening nurse’s report, and half a slice of toast at 20:30. No nausea. One formed stool at 23:00. GU: voiding into a urinal, clear yellow. Skin: intact; sacrum and heels checked at 02:00 and 06:00. Pain: none. Mobility: walks to the bathroom with 1 assist; bed low and call bell in reach, bed alarm on from 03:10. Lines: peripheral IV, 20 gauge, left forearm, day 3, site clean. Intake and output 19:00 to 06:00: 450 mL by mouth and 1,100 mL IV; urine 1,050 mL.
20:00: T 36.8 °C (98.2 °F), HR 82, BP 138/80, RR 16, SpO2 96% on room air. 03:12: T 36.6 °C (97.9 °F), HR 108, BP 156/88, RR 20, SpO2 96% on room air. 03:30: HR 90, BP 140/82, RR 16, SpO2 97% on room air. 06:00: T 36.7 °C (98.1 °F), HR 80, BP 134/78, RR 16, SpO2 96% on room air.
21:00: glargine 26 units subcutaneous, as ordered; bedtime glucose 9.8 mmol/L (177 mg/dL). 03:10: found him sitting on the edge of the bed, sweating heavily, tugging at his IV line, saying he had to open the shop. Oriented to his name only. Stayed with him and called a second nurse to the bedside. 03:12: capillary glucose 2.8 mmol/L (50 mg/dL). Pupils equal and reactive, face symmetrical, grips equal, moving all four limbs. 03:14: offered apple juice; he couldn’t follow the prompt to sip and pushed the cup away. 03:15: dextrose 50% 25 mL IV over 3 minutes, as the unit’s hypoglycemia protocol directs when glucose can’t be taken by mouth; IV checked before and after, flushing well with no swelling. Response at 03:30: glucose 6.2 mmol/L (112 mg/dL); sweating stopped; oriented to person, place, and time. “Did I do something daft?” 03:35: ate 6 crackers with cheese and drank 200 mL of milk, as the protocol directs when the next meal is more than an hour away. No fall; no injury on a skin check. 03:50: IV changed to dextrose 5% in 0.9% sodium chloride at 100 mL/h, as ordered. Glucose 04:30: 7.1 mmol/L (128 mg/dL); 05:30: 6.5 (117 mg/dL); 06:30: 6.4 (115 mg/dL). Oriented at each check. Slept from 04:45 to 06:00.
03:40: night hospitalist, by phone. Reported in SBAR order: glucose 2.8 mmol/L (50 mg/dL) at 03:12 with sweating and new confusion; dextrose 50% 25 mL IV at 03:15; 6.2 mmol/L (112 mg/dL) at 03:30, back to his usual; glargine 26 units at 21:00 after about 20% of supper; kidney function still recovering; no fall. Orders, read back and confirmed: capillary glucose every hour until 07:00, then before meals and at bedtime; IV changed to dextrose 5% in 0.9% sodium chloride at 100 mL/h until he eats at least half of each meal; tonight’s glargine reduced to 20 units, for the day team to review; any glucose below 4.0 mmol/L (70 mg/dL) treated under the protocol, then a call. She did not need to see him, as he was back to his usual. 06:40: updated her with the hourly readings; no new orders.
06:15, with him alert and oriented. Explained the low: his long-acting insulin kept working after a small supper, and kidneys that are still recovering clear insulin more slowly. Taught the early signs: sweating, shaking, a pounding heart, hunger, and feeling muddled. Asked him to press the call bell at once if he feels any of them, and to tell his nurse when he can’t finish a meal. Teach-back: he named sweating, shaking, and feeling muddled. “If I can’t eat my dinner, I tell you before the insulin.” He chose to tell his daughter himself when she visits at 10:00. Still to teach: the plan for his insulin at home, once the day team sets the dose.
Due: glucose before breakfast at 07:30, then before each meal and at bedtime; glargine 20 units at 21:00 unless the day team changes it. Pending: electrolytes and creatinine drawn at 05:00. Call if: glucose below 4.0 mmol/L (70 mg/dL), or sweating or confusion: treat under the protocol, then call the hospitalist. If he eats less than half a meal, tell the team before any insulin. Bed alarm stays on until the day team reviews. Goal for today: eats at least half of each meal, so the dextrose infusion can stop. Handed over at the bedside at 07:00.
Surgical ward, day shift 07:00 to 19:00
62-year-old woman, post-op day 2 after an L4–L5 posterior decompression and fusion with screws, for spinal stenosis with a slipped vertebra and left leg pain. Allergic to sulfonamide antibiotics (hives). High blood pressure, on amlodipine. Full code. Progressing well: drain out, walking with a walker and supervision, pain controlled on oral medication, voiding. On track to go home tomorrow. Entry written at 18:30.
Full assessment at 08:00; legs, incision, and pain rechecked every 4 hours. Neuro: alert and oriented. Strength 5/5 in both legs for hip flexion, knee extension, ankle dorsiflexion and plantarflexion, and big toe extension, the same as post-op day 1. Light touch intact in both legs. The burning pain down her left leg before surgery is gone; the numb patch on top of her left foot is smaller, she says. No headache on sitting up. Cardiovascular: pulse regular, pedal pulses strong on both sides, calves soft and not tender, compression devices on in bed. Respiratory: clear, room air, incentive spirometer 1,500 mL. GI: regular diet; ate 75% of breakfast and all of lunch; no nausea; passing gas; no bowel movement since surgery, bowel regimen given as ordered. GU: catheter removed on post-op day 1; voiding without trouble. Incision: 9 cm midline lower back, closed with skin glue; edges together, no redness, swelling, or clear fluid. Pain: incision 3/10 at rest and 5/10 walking, numeric scale; her goal is 4/10 or less at rest. POSS 1. Mobility: log rolls and sits up from her side without help; walks with a 2-wheeled walker and supervision. Morse Fall Scale 60: walker, saline lock, weak gait, and a second diagnosis; bed low, non-slip socks, call bell in reach. Lines: peripheral IV, 20 gauge, right forearm, day 3, saline lock, site clean. Intake and output 07:00 to 18:00: 1,600 mL by mouth; urine 1,450 mL in 5 voids; drain 15 mL before removal.
08:00: T 37.2 °C (99.0 °F), HR 78, BP 124/72, RR 16, SpO2 97% on room air. 12:00: T 37.4 °C (99.3 °F), HR 82, BP 128/74, RR 16, SpO2 98% on room air. 16:00: T 37.1 °C (98.8 °F), HR 76, BP 122/70, RR 14, SpO2 97% on room air.
08:15: oxycodone 5 mg by mouth for pain 5/10, 45 minutes before physiotherapy, after checking RR 16 and POSS 1. Response at 09:00: pain 3/10; walked 60 m (200 feet) with the physiotherapist, walker, and supervision; no dizziness, no leg pain. 09:30: closed suction drain removed, as ordered; tip intact; dry dressing over the site. Pain 4/10 during removal, 2/10 after. 10:00: incision dressing changed, as ordered; old dressing dry. 12:00: acetaminophen 1,000 mg by mouth, scheduled. 13:30: oxycodone 5 mg by mouth for pain 5/10. Response at 14:15: pain 3/10; with physiotherapy, climbed 6 stairs with one rail and supervision, one rest at the top, no leg symptoms. 16:30: walked 120 m (390 feet) with the walker, her husband beside her, nurse supervising; pain 4/10 while walking, 3/10 back in the chair. 18:00: acetaminophen 1,000 mg by mouth.
07:50: spine surgery resident, on morning rounds. Reported: drain 40 mL in the last 24 hours, legs unchanged, pain controlled on oral medication, voiding. Orders: remove the drain and change the dressing; discharge home tomorrow if she climbs a full flight of stairs with physiotherapy and her pain stays at 4/10 or less at rest on oral medication. 15:10: secure message to the resident: drain out, 6 stairs managed, pain 3/10 at rest. Reply at 15:25: discharge prescriptions to be written this evening; no new orders.
15:30, with her and her husband, using the unit’s spine surgery booklet. Taught: log rolling, and getting out of bed from her side; no bending, twisting, or lifting more than 4.5 kg (10 lb) until her surgeon says otherwise; short walks several times a day; changing position every 30 to 45 minutes when sitting; keeping the incision dry until the surgeon allows showers. Call the surgeon’s office for a temperature of 38.0 °C (100.4 °F) or more, or redness, swelling, or fluid from the incision. Go to the emergency department for new leg weakness or numbness, numbness in the groin or buttocks, or trouble passing urine or controlling her bowels; call 911 for chest pain or sudden shortness of breath. Teach-back: she showed a log roll and named the leg, groin, and bladder warning signs; her husband named the incision signs. Still to teach: stairs at home with her rail, and how to step down the oxycodone, with the discharge prescription tomorrow.
Due: acetaminophen at 24:00; oxycodone as needed, last dose at 13:30; bowel regimen at 21:00, as ordered; legs, incision, and pain at 20:00 and 04:00; compression devices on in bed. Call the on-call spine resident for any new leg weakness or numbness, clear fluid or fresh blood on the dressing, a headache on sitting up, or a temperature of 38.0 °C (100.4 °F) or more. No void in 6 hours: bladder scan, then call. Tomorrow: a full flight of stairs with physiotherapy at 09:00, finish discharge teaching, and remove the IV before she leaves. Goal for the night: pain 4/10 or less at rest, enough to sleep.
Who the note is about, which shift it covers, and when you wrote it. The reader needs the time of writing apart from the times things happened.
Avoid: Letting the signing time stand in for the shift. A note written at 06:55 about a 03:10 event needs 03:10 in the body.
Two or three lines the next nurse, or a physician scanning the chart, can take in at a glance.
Avoid: “Uneventful night” above a note that records a call to the hospitalist. The summary should match what follows.
Your own findings this shift. Most units expect a full system assessment early in the shift, then focused checks on the systems that matter for this patient or that changed.
Avoid: Rewriting the flow sheet line by line. Write what is new, abnormal, or decides care, and leave routine values on the flow sheet.
Each set with its time, so a reader can see the trend across the shift and around any event.
Avoid: “VSS.” Write the numbers. Stable to you may not be stable to the next reader.
What you did, each with a time, and what happened when you checked again. Each action gets its result.
Avoid: An action with no response. “Oxycodone given” without the pain score after it leaves the next nurse guessing whether it worked.
Who you told, when, what you said, and what was decided. On a quiet shift, this may be only morning rounds.
Avoid: “MD aware.” It doesn’t say who, when, what they heard, or what they decided.
What you taught, to whom, and how you checked it landed.
Avoid: “Education given.” Name the topic and what the patient could explain back.
What is due, what is pending, and what should make the next nurse pick up the phone.
Avoid: “Continue to monitor.” Say what to monitor, how often, and the number that should prompt a call.
A note signed at 06:55 that tells a 03:10 event without its own times hides how fast you acted. Write the time of each finding, dose, call, and recheck as it happened.
Stable against what? Write the finding and the baseline: “oriented to person, place, and time, his usual,” or “pain 3/10 at rest, down from 5/10.”
Write each order as you received it, who gave it, and that you read it back. If it isn’t in the note or the order system, the next nurse can’t act on it.
If a colleague gave the dextrose while you kept the patient safe, they chart the dose. Write what you did yourself, and name who did the rest.
“Monitor glucose” leaves the next nurse to decide what is too low. Write the threshold and who to call: below 4.0 mmol/L (70 mg/dL), treat under the protocol, then call.
Dictate between rounds or at the end of the shift, and Vero Scribe writes the nursing note in your template, with the times, readings, and doses you said. It can also draft from a bedside conversation, with the patient’s consent. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
A nursing note is the nurse’s written record of a shift or an event: what you assessed, the vital signs, what you did and when, how the patient responded, who you told, what you taught, and what happens next. It sits alongside the flow sheets and the medication record, and adds what they can’t show: the sequence, your reasoning, and the outcome.
Jot times as you go, so you don’t rebuild them at the end. Open with a short summary: better, the same, or worse. Then write your assessment, the timed vital signs, each intervention with the response you checked, any call to the provider with the orders you read back, what you taught and the teach-back, and what the next shift needs. Use the patient’s words where they matter.
They are ways to organize one. This template is a narrative note with headings: the shift in order, under fixed sections. DAR splits an entry into Data, Action, and Response around one focus. PIE files care under numbered problems, with Intervention and Evaluation. SOAP, or SOAPIE in nursing, runs Subjective, Objective, Assessment, Plan, then Intervention and Evaluation. Use the format your organization sets.
On most inpatient units, at least once a shift, plus a timed entry whenever something changes: a new symptom, a fall, a call to the provider, a procedure, or a transfer. Write as close to the care as you can. If you write later, record when the care happened and label the entry as late. Your organization’s policy and your regulator’s documentation standard set the rules where you practice.
Yes. Copy it, or download it as a Word or text file. No account needed.
System-by-system nursing assessment with pressure injury and fall risk, lines and drains, and escalation.
Assessment data, nursing diagnosis, SMART outcomes, interventions with rationale, and evaluation, one diagnosis at a time.
The bedside handoff in I-PASS order: severity, systems, lines, meds due, pending labs, risks, to-dos, and read-back.
Focus charting in four parts: the focus, the data behind it, nursing actions, and the timed patient response.
Problem, Intervention, Evaluation: numbered nursing problems carried from shift to shift, with the assessment on a flow sheet.
The longer read: an eight-step charting workflow, how to chart refusals, transfers, and corrections, a 12-point quality checklist, and reviewing AI drafts.
The same scenarios written as a progress note, a DAR note, and an SBAR handoff.
Shift notes, DAR entries, and SBAR calls, drafted for your review.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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