Nursing charting examples: SOAP, DAR, PIE, and narrative notes

Knowing the formats is only half of nursing documentation. What nursing students and new grads need most are real examples — actual note text showing how a completed chart entry looks for routine assessments, medication administration, post-operative care, patient falls, and IV complications.

This guide covers the four main documentation formats (SOAP, DAR, PIE, and narrative) with format explanations and a full section of realistic charting examples for the clinical scenarios you will encounter most often in practice. It also covers the documentation errors that can follow nurses into their careers if they’re not addressed early.

Quick-reference comparison: the four documentation formats

SOAP notes

SOAP is one of the most widely recognized documentation formats in all of healthcare. Originally developed by physician Lawrence Weed in the 1960s, it was designed to organize clinical information so any provider could quickly locate what they needed. Nurses use SOAP notes most often in ambulatory care, outpatient settings, and in roles where nursing and provider documentation overlap — including nurse practitioner practice.

The four components

Subjective (S): What the patient tells you. This includes the chief complaint in the patient’s own words, pain descriptions, symptoms, relevant medical and family history, current medications, and allergies. Document subjective information using quotation marks when quoting the patient directly. Example: “My chest has been tight since this morning and it gets worse when I breathe in.”

Objective (O): What you observe, measure, and collect. Vital signs, physical exam findings, oxygen saturation, laboratory results, and diagnostic data all belong here. This section is limited to observable, measurable facts — no interpretation.

Assessment (A): Your clinical interpretation of the subjective and objective data. For nurses, this includes nursing diagnoses and your analysis of the patient’s current condition. For nurse practitioners, this section includes a differential diagnosis and working diagnosis.

Plan (P): The interventions and next steps based on your assessment. This includes medications administered, orders requested, referrals, patient education, and follow-up actions.

SOAP note example: chest pain

Patient: 58-year-old male presenting to the ED with chest tightness.

S: Patient reports, “My chest has been tight and heavy since about 6 this morning. It’s a 7 out of 10. It gets worse when I breathe deeply and spreads to my left arm.” Patient denies nausea. PMH: hypertension, hyperlipidemia. Current medications: lisinopril 10 mg daily, atorvastatin 40 mg nightly. Allergies: penicillin (rash).

O: BP 158/94 mmHg, HR 102 bpm, RR 20/min, O₂ sat 96% on room air, Temp 37.0°C. Patient is diaphoretic and appears anxious. 12-lead ECG obtained: ST-segment elevation in leads II, III, aVF. Troponin I pending.

A: Acute chest pain with ST-elevation on ECG; rule out STEMI. Risk factors present: age, male sex, hypertension, hyperlipidemia. Pain unrelieved with current positioning.

P: Cardiac monitor initiated. IV access established, 18g right AC. 12-lead ECG transmitted to cardiology per STEMI protocol. Aspirin 325 mg PO administered per standing order. Provider notified. Patient kept NPO. Continuous vitals monitoring initiated. Patient and family educated on plan.

When to use SOAP

SOAP is the preferred format when clinical reasoning needs to be visible and auditable — in provider-nurse collaborative settings, complex multi-system assessments, and advanced practice documentation. Many nursing programs teach SOAP as the foundational framework for clinical thinking because it mirrors the diagnostic reasoning process.

DAR notes (focus charting)

DAR notes — also called focus charting — were developed in the 1980s as a more efficient alternative to narrative documentation in acute care settings. Rather than charting everything chronologically, focus charting organizes each note around a specific clinical concern or nursing diagnosis. The “focus” is identified at the top of the note, then the DAR entry follows.

The three components

Data (D): Assessment findings and information that describe the current state of the problem being addressed. This includes patient reports, vital signs relevant to the focus, and physical findings.

Action (A): The nursing interventions planned and implemented in response to the data. Both completed and anticipated actions are documented here.

Response (R): The patient’s response to the interventions. Did the pain improve? Did the patient tolerate the procedure? Was the goal achieved?

DAR note example: post-operative pain

Focus: Acute pain — post-operative day 1, abdominal surgery.

D: Patient reports pain at surgical incision site rated 8/10, described as sharp and constant. Patient is guarding abdomen, grimacing with movement, and reluctant to deep breathe. Last analgesic given 5 hours ago.

A: Provider notified of uncontrolled pain. Hydromorphone 0.5 mg IV administered per PRN order at 1430. Patient repositioned with pillow splinting technique demonstrated. Relaxation breathing coached. Reassessment scheduled for 30 minutes post-administration.

R: At 1500, patient reports pain decreased to 3/10. Patient demonstrated effective pillow-splinting technique and completed incentive spirometry ×5 breaths without difficulty. Will continue to monitor.

DAR vs SOAP: how to choose

DAR is faster and more efficient for documenting specific, identifiable problems during a shift. It works well when the nurse is charting ongoing care for a problem that has already been assessed — rather than performing a full clinical reasoning write-up. SOAP is stronger when you need to document the full thought process from complaint through plan, or when the note needs to stand as a complete clinical reasoning record.

Many acute care hospitals use DAR (or a hybrid focus charting system) for routine shift notes, reserving SOAP-style documentation for admission assessments and complex clinical events.

PIE charting

PIE charting was developed to tightly integrate documentation with the nursing process. Unlike SOAP and DAR, which can exist somewhat independently of formal nursing diagnoses, PIE documentation is explicitly structured around nursing diagnoses — making it particularly aligned with how nursing schools teach clinical reasoning.

The three components

Problem (P): A specific nursing diagnosis or identified patient problem, stated using NANDA-approved language where possible. The problem is labeled and numbered so it can be tracked across multiple entries.

Intervention (I): All nursing actions taken to address the identified problem — medications administered, repositioning, patient education, communication with the provider, and any protocols followed.

Evaluation (E): The patient’s response to the interventions and whether the nursing goals were met, partially met, or not met. This directly maps to the evaluation step in the ADPIE nursing process.

PIE note example: fluid volume deficit

Problem #1: Deficient fluid volume related to inadequate oral intake and post-operative nausea, as evidenced by dry mucous membranes, urine output 20 mL/hr × 3 hours, and patient report of thirst.

P1: Deficient fluid volume R/T post-operative nausea and decreased oral intake AEB dry mucous membranes, decreased urine output (20 mL/hr), and patient-reported thirst rating 7/10.

I1: 0.9% NaCl 500 mL IV bolus administered at 1015 per provider order. IV fluid rate increased to 125 mL/hr. Oral ice chips offered; patient tolerated 60 mL without nausea. Antiemetic (ondansetron 4 mg IV) administered at 1020 per PRN order. Accurate intake and output monitoring continued with urinary catheter in place. Patient instructed to report any increased thirst or dizziness.

E1: At 1200, urine output improved to 42 mL/hr over past 90 minutes. Mucous membranes remain slightly dry but improved. Patient reports thirst decreased to 2/10. Goal partially met — continue monitoring and fluid administration.

PIE and the nursing process

PIE is one of the most nursing-specific documentation formats because it forces the nurse to articulate a defined problem before documenting care. This mirrors the structure of nursing care plans, making PIE documentation particularly useful for nursing students who are learning to connect assessment findings to diagnosis, intervention, and evaluation.

Some facilities use a variation called APIE (Assessment, Plan, Intervention, Evaluation), which adds a formal assessment component before the problem is named.

Narrative notes

Narrative documentation is the oldest form of nursing charting. Rather than organizing notes into structured categories, narrative notes describe clinical events in chronological sequence — a written account of what happened, when, and how the patient responded.

When narrative notes are appropriate

Narrative documentation remains the standard in home health, long-term care, and skilled nursing facilities where a running account of care across a shift or visit is expected. It is also the format of choice for incident reports, unusual occurrences, and situations where the sequence of events is legally or clinically significant — such as a fall, a medication error, or a rapid deterioration.

Narrative note example: rapid deterioration

At 0215, patient found in bed unresponsive to verbal stimuli. Sternal rub applied — patient grimaced and opened eyes briefly to painful stimuli. O₂ sat noted at 82% on 2L NC. RR 6/min, shallow. Provider Dr. Chen notified immediately at 0216. O₂ increased to 10L via non-rebreather mask per standing order. Rapid Response Team called at 0217. O₂ sat improved to 91% by 0220. Patient transferred to ICU at 0235 in stable but critical condition. Family notified by charge nurse at 0240. Complete documentation of assessment and interventions filed in incident report per policy.

Why narrative is being phased out

In modern EHR environments, narrative notes create problems: they are difficult to search, inconsistently structured across nurses, and time-consuming to write and review. Most large hospital systems now use structured documentation templates (with drop-down menus, checkboxes, and discrete data fields) that produce structured data rather than free text. Narrative free-text fields persist for “additional notes” and special circumstances, but they are no longer the primary documentation method in most acute care EHR implementations.

Nursing charting examples by clinical scenario

The examples below show how completed nursing notes actually read in practice. Each scenario is presented in the most appropriate format for that clinical context, with a brief note on why that format fits. Use these as reference points when building your own charting skills in clinicals or simulation.

Routine shift assessment (head-to-toe, narrative/structured format)

This type of note documents a systematic head-to-toe assessment at the start of a shift. Most EHRs capture this via structured flowsheets, but free-text narrative notes in this format are still used in many long-term care and home health settings. The head-to-toe assessment guide covers the full systematic sequence that generates this data.

Patient: 72-year-old female, medical-surgical unit, day 2 post-admission for community-acquired pneumonia.

0730 — shift assessment note

Patient alert and oriented ×4 (person, place, time, event). Denies pain at rest; rates cough-related chest discomfort 3/10. Skin warm, dry, and intact. Pupils equal and reactive to light bilaterally. Follows commands appropriately.

Respiratory: RR 18/min, O₂ sat 95% on 2L NC (up from 92% on 3L yesterday). Breath sounds with decreased aeration at right base; coarse crackles audible at right lower lobe. Productive cough — moderate amount yellow-green sputum. Encouraged deep breathing and coughing q2h. Incentive spirometer at bedside; patient using independently.

Cardiovascular: HR 84 bpm, regular rhythm. BP 126/74 mmHg. Cap refill <2 seconds bilateral upper and lower extremities. No peripheral edema noted. Telemetry: NSR, no ectopy.

GI/GU: Abdomen soft, non-tender, bowel sounds active ×4 quadrants. Last BM yesterday. Foley catheter in place — urine clear, yellow, output 55 mL/hr over past 2 hours.

Musculoskeletal: Moves all extremities with equal strength. Ambulated 60 feet in hallway with 1-person assist at 0715 — tolerated without dyspnea or desaturation. Fall risk score 18 (high); bed alarm active, call light within reach.

Skin: Sacral area assessed — no breakdown noted. Repositioned to left lateral per turning schedule.

IV access: 20g PIV right forearm, patent, site without redness, swelling, or tenderness. Infusing IV antibiotics per schedule.

Plan: Continue current antibiotic regimen. Reassess O₂ requirements at 1200. Encourage ambulation and pulmonary hygiene. Patient and daughter (present at bedside) educated on importance of deep breathing exercises.

Medication administration — PRN pain medication (DAR format)

PRN medication charting documents the indication, administration, and patient response. DAR is well-suited here because the note is centered on a single, identifiable clinical focus. See also: safe medication administration and pain assessment.

Patient: 48-year-old male, orthopedic unit, post right total knee replacement, POD 2.

Focus: Acute pain — right knee, post-operative.

D: Patient reports right knee pain rated 7/10, described as throbbing and aching, worse with movement. Patient requesting pain medication. Last opioid dose administered at 0900 (oxycodone 5 mg PO); current time 1345 — within appropriate dosing interval. Vital signs: BP 138/82, HR 88, RR 16, SpO₂ 98% on room air. Sedation scale 1 (awake and alert).

A: Oxycodone 5 mg PO administered at 1350 per PRN order. Patient instructed to use ice pack to right knee 20 minutes on/off per order. Leg elevated on pillow per physician order. Non-pharmacological measures reviewed: repositioning, distraction techniques. Reassessment planned for 1420.

R: At 1425, patient reports pain decreased to 3/10. Ambulated 20 feet in hallway with PT at 1430; tolerated without significant increase in pain. SpO₂ 98% throughout. No adverse effects noted. Will continue to monitor per shift schedule.

Medication administration — IV antibiotic (narrative format)

IV antibiotic administration notes document pre-administration assessment, infusion details, and patient response. Many hospitals capture this primarily in the MAR, with a supplemental nursing note for reactions or notable observations.

Patient: 31-year-old female, medical unit, admitted for pyelonephritis.

1400 — IV antibiotic administration note

Ceftriaxone 1g IV piggyback administered per physician order. Pre-administration: patient allergies verified (NKDA). IV site assessed — 18g PIV left forearm, no redness, swelling, or tenderness; site patent with good blood return on aspiration. Medication label verified against MAR per five rights. Medication infused over 30 minutes via IV pump at rate 50 mL/hr (in 50 mL NS). Patient instructed to notify nurse if she experienced any itching, rash, difficulty breathing, or swelling during infusion.

Patient tolerated infusion without adverse reaction. At 1430, infusion complete. IV site reassessed — no signs of infiltration or phlebitis. Patient reports right flank pain improved slightly from 6/10 to 5/10 since this morning’s dose. Temperature 37.8°C (down from 38.6°C at 0800 admission). Will continue to monitor for therapeutic response and adverse effects. Next dose due at 0200.

Post-operative nursing note (SOAP format)

The immediate post-operative period requires comprehensive documentation of the patient’s return from anesthesia, pain status, hemodynamic stability, and surgical site. SOAP works well here because it mirrors the structured assessment a provider needs to review. See the postoperative nursing guide for the full clinical context.

Patient: 61-year-old female, PACU transfer to surgical floor, status post laparoscopic cholecystectomy.

S: Patient reports pain at umbilical port site rated 5/10, described as sharp with movement and dull at rest. States she feels “groggy” but knows where she is and what procedure she had. Denies nausea. Reports right shoulder discomfort (rated 2/10) — patient educated that referred pain from residual CO₂ gas is expected and typically resolves within 24–48 hours.

O: Arrives from PACU at 1545. Alert and oriented ×4. Airway patent, breathing spontaneously. BP 118/72 mmHg, HR 76 bpm, RR 14/min, SpO₂ 98% on 2L NC. Temp 36.4°C. Three laparoscopic port sites to abdomen — surgical dressings dry and intact, no bleeding or drainage noted. Abdominal binder in place per surgeon order. Foley catheter removed in PACU; patient voided 120 mL clear yellow urine in PACU prior to transfer. IV access: 18g right AC, patent. Last OR analgesic: ketorolac 15 mg IV at 1420. PACU pain score at discharge: 4/10.

A: Patient hemodynamically stable post-general anesthesia. Pain partially controlled with mild-to-moderate incisional discomfort. No evidence of surgical site complications. Residual anesthesia effects (drowsiness) expected and resolving.

P: Continue O₂ 2L NC; wean to room air when SpO₂ consistently ≥95%. Pain management per post-op PRN orders. Ondansetron 4 mg IV available PRN if nausea develops. Advance diet from clears per surgeon order. Ambulate with assistance by 1800 if patient tolerates. Monitor surgical sites q4h and prn. Patient and husband educated on activity restrictions, port site care, and signs of complications — written discharge instructions provided. Surgeon notified of patient’s arrival to floor and current status.

Patient fall documentation (narrative format)

Fall documentation is one of the most legally significant chart entries a nurse will write. The narrative format is standard because the sequence of events matters. Document only objective observations — what you saw, heard, and measured. Do not speculate about cause. See also: fall prevention nursing.

Patient: 81-year-old male, medical unit, admitted for COPD exacerbation. Fall risk score 22 (high).

1823 — fall event note

Loud sound heard from patient room 412. Upon immediate entry, patient found on floor in prone position between bed and bathroom door, approximately 4 feet from the bed. Bed alarm noted sounding. Patient alert and responsive — stated, “I tried to get up to go to the bathroom.” Denies loss of consciousness before or during the fall. Patient assisted to supine position with assistance of charge nurse.

Head-to-toe assessment completed immediately: No visible lacerations, deformities, or open wounds. Patient denies head pain; pupils equal and reactive bilaterally. Right wrist tender to palpation with range of motion limited by pain — patient unable to fully extend wrist against resistance. No other point tenderness. BP 132/78, HR 90, RR 18, SpO₂ 94% on 2L NC.

Provider Dr. Patel notified at 1826 of fall and right wrist injury. Orders received: right wrist X-ray stat, ice pack to right wrist, neurovascular checks q1h ×4. X-ray technician called to bedside at 1830. Patient transferred to bed with full assist ×2. Call light and urinal placed within reach. Bed lowered to lowest position, side rails up ×3. Patient instructed not to get up without calling for assistance.

Family contacted at 1835 — patient’s daughter notified by telephone and informed of fall, current status, and ordered X-ray. Charge nurse notified.

Incident report filed per facility policy at 1900.

1950 — follow-up note: Right wrist X-ray resulted — no fracture per radiologist preliminary read. Provider updated. Neurovascular check completed: right hand warm, cap refill <2 sec, sensation intact in all digits, able to flex and extend fingers with mild pain. Ice pack applied. Patient resting in bed, O₂ sat 95% on 2L NC, denies further discomfort beyond right wrist soreness.

IV site assessment and infiltration documentation (DAR format)

IV site complications must be documented promptly and completely. DAR is efficient for this focused clinical event. See also: IV insertion and care.

Patient: 54-year-old male, oncology unit, receiving IV hydration.

Focus: IV site complication — suspected infiltration, left forearm PIV.

D: At 1110, patient reports left forearm pain and swelling at IV site, rated 4/10. Upon assessment: 22g PIV left forearm, inserted by day shift at 0630, now 4.5 hours old. Site with visible swelling — approximately 3 cm × 2 cm raised area around insertion point. Skin cool and pale over swollen area. No blood return on aspiration. IV pump alarming with occlusion alert. Surrounding tissue firm to palpation. IV fluid (0.9% NaCl at 100 mL/hr) paused immediately. Infiltration scale assessed: Grade 2 (skin blanched, edematous, cool to touch, up to 6 inches in any direction, pain with or without pitting edema).

A: IV infusion stopped at 1110. IV catheter removed. Direct pressure applied to insertion site for 2 minutes — minimal bleeding. Affected extremity elevated on pillow. Warm compress applied to infiltrated area per facility protocol. Patient instructed to notify nurse if pain, redness, or swelling worsens. New IV access required: 20g PIV established right antecubital at 1125 on first attempt, good blood return, flushes without resistance. IV fluids restarted at 1130. Provider notified of infiltration and new IV site placement.

R: At 1200, left forearm swelling decreased — estimated 2 cm × 1.5 cm, less firm. Skin color returned to baseline. Patient reports left forearm pain decreased to 1/10 with warm compress in place. New right AC site without redness, swelling, or tenderness. IV infusing without difficulty at ordered rate. Patient verbalized understanding of IV site monitoring instructions.

Common charting mistakes to avoid

Understanding documentation formats is only half the battle. These errors are among the most common — and most consequential — in nursing practice.

Late entries: Document as close to real time as possible. If a late entry is necessary, clearly label it as such with the time of the actual occurrence and the time of documentation. Backdating or altering timestamps is falsification of medical records.

Dangerous abbreviations: The Joint Commission maintains a “Do Not Use” list that includes abbreviations like “U” for units (mistaken for a zero), “IU” for international units, and trailing zeros (e.g., 1.0 mg). Many medication errors have originated in documentation. Learn your facility’s approved abbreviation list.

Copy-paste errors: In EHR systems, copy-pasting previous notes without updating them is a significant source of documentation error. A patient’s pain level from yesterday’s note appearing in today’s is both inaccurate and potentially dangerous for clinical decision-making.

Incomplete assessments: Charting “within normal limits” for an entire system without performing the assessment is a legal and ethical violation. Document only what you have personally assessed, observed, or performed.

Vague language: “Patient seems uncomfortable” is not useful documentation. “Patient rates pain 6/10, diaphoretic, guarding right lower quadrant” is. Use measurable, specific, objective language whenever possible.

Documenting for others: Never document care performed by someone else as though you performed it. If you observed another nurse administer a medication, document who gave it.

Subjective opinions about behavior: Notes like “patient is being difficult” or “family is demanding” are inappropriate and unprofessional. Describe observable behaviors instead: “Patient declined repositioning and stated, ‘Leave me alone.’ Family member raised voice and requested to speak with charge nurse.”

Omitting the patient’s response: Every intervention note should include how the patient responded. Administering a medication and stopping there is incomplete. Did pain improve? Did the patient tolerate the procedure? The response closes the clinical loop and documents whether the intervention worked.

Nursing documentation in Epic and Cerner

Most US hospitals use either Epic or Cerner as their electronic health record platform. Understanding how these systems handle nursing documentation will prepare you for clinical rotations.

Epic uses a system called FlowSheets for routine nursing assessments — structured grids where nurses select from standardized options for findings like skin integrity, pain, orientation, and IV site condition. Progress notes in Epic are typically templated using SmartText macros, which auto-populate structured text based on the nurse’s flowsheet entries. SOAP-style notes are common for provider documentation in Epic; nursing notes more often follow a structured assessment format rather than a classic SOAP or DAR layout. Focus notes resembling DAR can be created via the “Problem-Oriented” note type.

Cerner (now Oracle Health) uses a similar structured-charting approach through its PowerChart interface. Nursing assessments are completed via structured forms, with free-text available for each section. Cerner’s “Dynamic Documentation” feature guides nurses through assessment sections that loosely mirror the SOAP framework without requiring nurses to label entries that way.

In both systems, the underlying principle of every format — document what you assessed, what you did, and how the patient responded — remains constant. What changes is how that information is entered. Nursing students should expect significant orientation time on whichever EHR their clinical facility uses, and should not assume that knowing one system transfers immediately to the other.

How documentation appears on the NCLEX

The NCLEX-RN and NCLEX-PN both test documentation knowledge, primarily through clinical judgment questions. Understanding documentation in this context means knowing what to chart, when to chart it, and the sequence in which actions should occur.

Documentation sequence questions ask you to identify the correct order of actions — and whether documentation comes before or after a clinical intervention. In most scenarios, assessment and intervention come first; documentation follows. Never document before you act.

“Nurse’s note” interpretation questions present a charted note and ask you to identify what the documentation indicates about the patient’s condition, what priority problem is present, or what the nurse should do next. These questions test your ability to read documentation critically and translate it into clinical judgment.

Priority action framing: On the NCLEX, questions that ask “which action should the nurse take first?” sometimes include “document the findings” as an option. As a rule, documentation is never the first priority when a patient requires immediate assessment or intervention. Always stabilize the patient first.

Legally sensitive scenarios: The NCLEX tests nurses on correct documentation practices — how to correct an error in a paper chart (single-line strikethrough, “mistaken entry,” date and initials), the meaning of late entries, and what constitutes falsification.

For a broader look at how clinical reasoning connects to what you document, the ADPIE nursing process guide covers assessment through evaluation in detail. The head-to-toe assessment guide provides the systematic framework that generates the objective data you’ll document. For nurse-to-provider communication, SBAR is a separate — but complementary — communication format that differs from charting. The shift report and handoff guide covers how documented information transfers between nurses at change of shift.

Sources

1. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278(11):593–600.
2. Pearce PF, Ferguson LA, George GS, Langford CA. The SOAP note: revised. J Am Acad Nurse Pract. 2016. Available at: https://www.ncbi.nlm.nih.gov/books/NBK482263/
3. Wisconsin Technical College System. Documentation. In: Nursing Fundamentals, 2nd ed. Open Resources for Nursing (Open RN). Available at: https://wtcs.pressbooks.pub/nursingfundamentals/chapter/2-5-documentation/
4. Toronto Metropolitan University. Methods of documentation. In: Documentation in Nursing, 1st Canadian ed. Available at: https://pressbooks.library.torontomu.ca/documentation/chapter/methods-of-documentation/
5. The Joint Commission. Facts about the official “Do Not Use” list of abbreviations. Available at: https://www.jointcommission.org
6. Agency for Healthcare Research and Quality. Fall response documentation. Falls Management Program. Available at: https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html