A nursing note should help the next person understand what happened, what you found, what you did and what still needs attention. Long notes are not automatically good notes. A short entry can be useful when it is specific, accurate and connected to the patient’s care. This guide gives students and early-career nurses a practical way to organise their writing.
Start with professional record-keeping principles
The UK Nursing and Midwifery Council’s Code requires clear and accurate records, made at the time of an event or as soon as possible afterwards. It also emphasises recording relevant risks and actions, identifying the author, avoiding speculation and keeping records secure. These are useful learning principles; the UK Code is not Nigeria’s regulatory code. Nurses practising in Nigeria should follow Nursing and Midwifery Council of Nigeria requirements and their employer’s documentation policy.
Four questions that make a note easier to follow
- What prompted the entry? State the concern, assessment, procedure or change in condition.
- What did you find? Separate what the patient reported from what you observed or measured.
- What action did you take? Describe the care, communication and escalation that actually occurred.
- What happened next? Record the response, reassessment and outstanding plan.
This four-question structure is a teaching aid, not a replacement for your facility’s approved charting format. Some settings use narrative notes, while others use structured electronic fields or formats such as SOAP. The best format is the one approved for your workplace and used accurately.
Example: replacing a vague entry
Vague entry: “Patient educated. Understands.”
Clearer teaching example: “14:10 — Explained the appointment date and location using the discharge sheet. Asked the patient to describe the follow-up plan in their own words. Patient correctly stated the clinic location and appointment date but asked how to arrange transport. With the patient’s agreement, referred the transport concern to the discharge coordinator. Follow-up required before discharge.”
This is a fictional example. Its value lies in showing what was explained, how understanding was checked and what remained unresolved. In a real record, include the appropriate date, patient identification and author details according to local policy. Never copy an example as though it describes care you personally provided.
Use observations instead of labels
Words such as “difficult,” “lazy” or “uncooperative” do not explain a patient’s concern. Compare “patient refused” with a description of what was offered, the patient’s stated reason, information provided, and the person informed. Where relevant, record the patient’s own words accurately. This helps another clinician understand the situation without inheriting an unsupported judgement.
Similarly, “doctor informed” leaves several questions unanswered. A useful entry identifies the clinician contacted, the time, the concern communicated, the advice or plan received and any follow-up. Do not document a response that has not yet occurred. If contact was unsuccessful, record the attempt and the next escalation step taken under local procedure.
Corrections, late entries and confidentiality
Follow your organisation’s process for correcting records, preserving the original entry and the audit trail. Make late entries clearly identifiable rather than changing the time to suggest that you wrote them earlier. Use only your own authorised login, and protect paper and electronic records from unauthorised access. Never use identifiable patient notes in social media posts or teaching examples without the required lawful authorisation.
A quick review before signing
- Am I writing in the correct patient’s record?
- Are the date, time and sequence clear?
- Have I distinguished reported information from my own findings?
- Does the note describe care that actually happened?
- Are the response and any outstanding actions clear?
- Have I used approved terminology and identified myself correctly?
During clinical placement, ask a supervisor to review a practice entry using a fictional case. Focus on one improvement at a time, such as making observations more specific or explaining the follow-up plan. The aim is a record that another professional can understand without having to guess.
Professional reference
UK Nursing and Midwifery Council: The Code, particularly section 10 on keeping clear and accurate records. Consult your local nursing regulator and facility policy for the requirements that apply to your practice.
Educational guidance for nurses and students. All examples are fictional and are not patient records.