What is a Nurse Note Template?
Nurses must routinely take many different types of notes to ensure the quality of their patients’ clinical documentation. All this administration can take up a big chunk of nurses’ days, and that’s where our template comes in!
A template is a skeleton for your nurse notes that includes pre-made sections, headings, and formatting to save you time and keep your notes consistently structured.
While our template includes sections for your patient’s information, we have kept the body section simple enough to allow for the many different styles of nurse note-taking. Include your note, whatever type or style you prefer, in this large note section.
This template can be used for all sorts of nurse notes, including progress notes, SOAP notes, F-DAR notes, incident notes, narrative notes, or any other type of routine, concise patient note. This template is available as a free, interactive PDF download, and it can also be printed out if taking notes by hand is more your style.
How to Use this Template for Nurse Notes
Start using this nurse note template for your note-taking by following these simple steps.
Download the template
This template is available as a free PDF download on this page, or it can be accessed from within Carepatron. While we recommend keeping your notes digital, you can continue to print the PDF download and fill it in by hand if you prefer.
Fill in the patient information
Fill in your patient’s information in the header of the template. Include their name, date of birth, gender, and if applicable, their identifier and ward number.
Diagnosis and Reason for Admission
These sections are designed to be concise summaries of your patient’s chief complaint (CC), separating their overall diagnosis from the specific reasons for their admission.
Write your note
The body of the note can be taken in whichever style you prefer. Keep your note concise and stick to the facts, but ensure you include any relevant details regarding the interaction with your patient.
Sign and date your note
Add your name, date, and signature at the bottom of the template, and ensure you store the note securely due to the confidential patient health information it contains.
Nurse Note Example (Sample)
There are so many different situations this template could be used in, from a routing progress note to a detailed incident note, the completed version of this template could look completely different. Your nurse notes are likely a different style to your colleagues, and so we can expect differences in notes even between nurses at the same hospital. However, in order to illustrate what one finished version of this template could look like, we have created an example nurse note. This sample is a progress note taken in the SOAP format for a diabetic patient.
Who Can Use this Printable Nurse Note Template?
This template is designed for registered nurses (RN’s) working in an inpatient or ward setting who routinely need to take different types of notes on their patients. Nurses who may find this template useful to incorporate into their clinical practice include:
- Perioperative nurses
- Occupational health nurses
- Pediatric nurses
- Hematology nurses
- Hospice care nurses
- Cardiac care nurses
- Geriatrics nurses.
RN’s aren’t the only ones who can use this template, however. Others who may benefit from using this template include:
- Nurse assistants
- Trainee or student nurses
- Healthcare assistants
- Allied health professionals.
No matter the specialty, or the stage of their career, there are many benefits for nurses to incorporate a template into their note-taking practice.
Why is this Template Useful for Nursing?
One template, many types of notes
Nurses may have to take many different types of notes throughout their day. Luckily, our nurse note template is simple enough to enable them to take whatever type of note they need.
Dedicated spaces for patient information
Don’t worry about forgetting an important piece of patient information with our patient information header which includes spaces for their name, date of birth, gender, identifier, ward and room number, and the date and time of your interaction.
You won’t need to chase up the anonymous writer of a nurse note again with spaces for the nurse’s name, signature and date of writing.
Benefits of Nurse Notes
Save time formatting
Our nurse note template means you can save time formatting every note. Additionally, you have the option to add in extra headings and subsections as you like, but this template can also be used as it is.
Improve your organization
Staying organized is a superpower for nurses, and our template is designed to help you keep track of all the notes you take throughout the day. Include the date, time and patient details in every note to ensure your notes can be chronologically accessed, and standardize your note-taking practice.
Keep your administration digital
Keeping your notes digital has huge advantages, including improving legibility for others, saving time from handwriting, improving accessibility, and better security by utilizing digital encryption.
See key information at a glance
Our patient header and separate spaces for diagnosis and reason for admission make it easy for others to quickly get the key information from your note. This can be useful for aiding clinical decision-making and improving your record-keeping.
Provide evidence to third parties
There are some situations where you will need to provide evidence of your clinical decision-making, or of the hours spent attending to patients for audit or legal purposes. This template provides great proof of your note-taking and decision making skills, and having a standardized template to provide to third parties will ensure your notes can be easily understood.
Why Use Carepatron For Nurse Notes?
Carepatron is a fantastically integrated software solution for nurses, nurse practitioners, or nurse managers who want to reduce their administrative workload.
Fill out your nurse notes electronically, store them in our HIPAA-compliant, digitally encrypted platform, and access them securely wherever you need via our mobile or desktop platform. Save time transferring data across multiple platforms by utilizing Carepatron’s comprehensive, practice management tools such as a client and practitioner list, integrated calendar, and unified workflow capabilities.
Your patients will appreciate having access to their dedicated Carepatron client portal which allows them to book appointments, and access payment information and their medical records, including their nurse notes.
As well as note-taking, use Carepatron to schedule patient appointments, send automated SMS or email appointment reminders, manage billing and coding, and access this template, and many others including nursing SOAP notes, nurse progress notes and chart notes, to streamline your administration process.