How to Write a Nursing Progress Note (With Examples)
A progress note answers three questions: what did you observe, what did you do, and what happened next. Here is how to structure one clearly.
The short answer
Follow observation, action, response. Every solid progress note takes that shape, whether it is one line or a paragraph. Your employer may require a particular format (narrative, SOAP, focus charting with data-action-response, or electronic fields), but the content underneath is the same.
The basic structure
Example (fictional patient)
Patient D reports pain 6/10 in lower abdomen at 1415. Acetaminophen 650 mg PO given per order. Reassessed at 1445; pain reported as 2/10.
Findings: plain and specific
Avoid "vitals okay." Write the values: "BP 118/76, HR 78, RR 16, temp 36.8 °C at 0800." If you chart vitals in a flowsheet, a narrative line can still add context such as how the patient looked and what they said.
Always record the response
An intervention with no follow-up reads as incomplete. If you gave a medication, repositioned a patient or called a physician, show what happened afterward, even briefly.
A full short note
Example (fictional patient)
1200: Patient E walked in hallway with steady gait, no dizziness reported. Denies pain. Vitals per flowsheet. Family at bedside, no concerns voiced.
Formats you may meet
- Narrative: free text in time order.
- SOAP: subjective, objective, assessment, plan.
- Focus charting (DAR): data, action, response under a stated focus.
- Charting by exception: only deviations from defined norms are written, so your unit must have clear norms and policy for it.
Use the one your employer or program requires. If you are unsure, ask.
What to leave out
Personal opinions, assumptions about motive, and anything you did not observe or hear from the patient. If you infer something, label it as your assessment and add the evidence. Avoid labels like "non-compliant"; record what the patient did or declined and what information you gave.
Template
Time: ___ Observation or patient report: ___ Action: ___ Response and recheck time: ___ Communication: ___ Plan: ___
Where Fiabita fits
Fiabita is an educational and documentation-support tool. Its "Clean up my note" tool can help you reword practice notes in clearer professional language, and Study Lab can turn your own course material into quizzes and flashcards. Treat every output as a draft to verify, do not enter information that could identify a real patient, and follow your program or workplace policy.
FAQ
Q: How long should a progress note be?
As long as it takes to give the finding, the action and the response clearly. Routine entries can be short.
Q: Should I write in full sentences or short phrases?
Either can work if the meaning is clear and the abbreviations are approved by your employer. Avoid shorthand another reader could misread.
Q: Can I copy forward yesterday's note?
Be careful. Copied text can carry outdated information. Check your employer's policy and make sure every statement is true for today.
Sources and further reading
- College of Nurses of Ontario: Documentation practice standard
- CNPS: Documentation for Nurses (guidelines)
- ISMP Canada: Do Not Use list of dangerous abbreviations, symbols and dose designations
Always check the current version of each source and your own regulator's standards; links and wording can change.