How to write a nursing note in English

Short answer: A good nursing note states what you observed, measured and did, in factual words, with the date, time, your signature and your title. The College of Nurses of Ontario (CNO), the British Columbia College of Nurses and Midwives (BCCNM) and the American Nurses Association (ANA) all ask for clear, accurate and timely documentation, and CNO and BCCNM both say you must never chart care before you give it.

Each employer's policy and each regulator's standard decide what is required; this page teaches language, not policy.

What regulators expect

• CNO (Ontario), Documentation practice standard, in effect February 1, 2026: clear, complete and accurate notes, in time order, written at the time of care or soon after. CNO warns that care not charted may be read as care not done.
• BCCNM (British Columbia), "Nurses: Documentation", in force April 1, 2026: clear, concise, chronological, factual, timely and legible notes, with more detail for acutely ill or high-risk clients.
• ANA (United States), Principles for Nursing Documentation: the first of its six principles lists qualities such as accurate, clear, concise, complete and timely.
• Nursing and Midwifery Board of Australia (NMBA): accurate, comprehensive and timely documentation of assessment, planning, decisions, actions and evaluation.

Both Canadian standards also ask for respectful language that does not discriminate.

Write facts, not judgments

CNO defines objective information as what you observe or measure, without your own feelings or interpretation.

Tense, time and the patient's own words

• Use the past tense for what you did: "Administered", "Notified".
• Use the present tense for what the patient says or what you find: "States", "Skin warm and dry".
• Never chart in the future tense for care you have not given.
• Start each entry with the date and time, in your employer's format.
• Put the patient's exact words in quotation marks: States, "My chest feels tight." When you summarize, leave them out: Reports chest tightness.

Late entries and corrections

If you forget to chart something, write a late entry. CNO and BCCNM both ask you to label it and record when you write it and when the care happened. For example: "Late entry, written 11/10 at 16:20, for care given at 13:00."

If you make an error, do not delete it. CNO says the original entry must stay legible and retrievable. BCCNM adds that you correct it promptly, reduce any harm it caused and follow your employer's method. Never change another person's entry, and never sign a record you know is false.

Two sample notes

Sample 1, routine assessment

11/10, 08:30. Awake, alert and oriented to person, place and time. Lungs clear on both sides. Abdominal incision dry and intact. Rates incision pain 3 out of 10. Walked in hallway with walker, no dizziness. Call bell within reach. (signature), RN

Sample 2, change in condition, provider notified

11/10, 14:10. States, "I can't catch my breath." Respiratory rate 28, oxygen saturation 88% on room air, heart rate 112. Crackles in both lower lobes. Raised head of bed. (signature), RN

11/10, 14:15. Dr. B, attending physician, notified by telephone of shortness of breath, vital signs and lung sounds. Dr. B ordered oxygen 2 liters per minute by nasal cannula, furosemide 40 mg intravenous once now and a portable chest X-ray now. Orders read back and confirmed. (signature), RN

11/10, 14:40. Oxygen on at 2 liters per minute by nasal cannula. Furosemide given as ordered. Oxygen saturation 94%, respiratory rate 22. Chest X-ray done. (signature), RN

Sample 2 records who you called, their title, how you reached them and their response, as CNO and BCCNM ask. To prepare, see SBAR: how to call a physician in English.

15 useful charting verbs and phrases

1. States, "..." (exact words)
2. Reports (a summary)
3. Denies (pain, nausea)
4. Observed
5. Assessed
6. Administered (drug, dose, route)
7. Declined (with the patient's reason)
8. Tolerated without (a symptom)
9. Repositioned to (left side)
10. Walked (distance) with (help or device)
11. Notified (name, title) by (telephone, in person)
12. Orders read back and confirmed
13. Able to state (what was taught) in own words
14. No change from (time) assessment
15. Call bell within reach

What to do next

1. Ask in orientation for your employer's documentation policy and approved abbreviation list. Neither CNO nor BCCNM sets an abbreviation rule in its current standard. See Nursing abbreviations in English, and the ones that must not be used.
2. Rewrite two old notes in the "Write this" style.
3. Practice Shift handover in English: phrases that work.

Common questions

Can I co-sign a note for a colleague?

CNO says nurses do not co-sign entries. Both regulators say you chart only care you gave yourself, with exceptions such as a designated recorder at a cardiac arrest (CNO) or an emergency (BCCNM).

Can I use an AI tool to write notes?

CNO says you must review any text that artificial intelligence (AI) produces. BCCNM allows AI help only with employer approval, and you stay accountable for every word.

English for Nurses is free. All Nursing Exams, NCLEXPace and NPractitioner are run by the same team.

Sources

• College of Nurses of Ontario, Documentation practice standard (PDF): https://cno.org/Assets/CNO/Documents/Standard-and-Learning/Practice-Standards/41001_documentation.pdf (checked November 10, 2026)
• BCCNM, Nurses: Documentation practice standard: https://www.bccnm.ca/RN/PracticeStandards/Pages/documentation.aspx (checked November 10, 2026)
• American Nurses Association, Principles for Nursing Documentation (PDF): https://www.nursingworld.org/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf (checked November 10, 2026)
• Nursing and Midwifery Board of Australia, Registered nurse standards for practice: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx (checked November 10, 2026)