How to write a nursing note
Other platforms explain it with text and video. In Making Synapses you practice it on the patient.
The nursing note is a legal record and a handoff tool. Care that is not documented may be treated as not done.
Step by step
Document promptly
Write as soon as possible after giving care, with the date and time. [1]
Choose a format
Follow your facility's format, such as narrative, SOAPIE, DAR (data, action, response) or charting by exception. [1]
Record objective data
Describe what you saw, heard and measured. Quote the patient's own words. [1]
Record interventions
Write what you did, such as medicines given, wound care or turning the patient. [2]
Record the response
Write how the patient responded and any provider you notified. [1]
Avoid documentation errors
Use only approved abbreviations. Correct mistakes per policy and never delete or hide an entry. [3]
Sign the entry
Sign with your name and credentials. [1]
Common errors
- Writing opinions such as difficult patient.
- Charting care before it is done.
- Leaving out the patient's response.
Practice it in Making Synapses
In Making Synapses you do this on the patient, not on paper: every step goes on the checklist with a score, and in Teach mode Blocky tells you what comes next.
Making Synapses cases that train this skill
- Fall risk at home, older adult
- Parkinson disease, home safety
- Intimate partner violence in pregnancy
- Neonatal jaundice
- Pressure injury in a wheelchair user
- Bleeding after prostatectomy
33 Making Synapses cases train this skill: open the case library
Sources
- Open RN, Nursing Fundamentals 2e (CC BY 4.0)
- NCSBN 2026 NCLEX-RN Test Plan
- The Joint Commission, National Patient Safety Goals
- AAMC Core Entrustable Professional Activities (Core EPAs)
- AHRQ Health Literacy Universal Precautions Toolkit (Teach-Back)
Facts and steps follow AAMC Core Entrustable Professional Activities (Core EPAs); AHRQ Health Literacy Universal Precautions Toolkit (Teach-Back). Making Synapses is not affiliated with these organizations. Updated: 2026-10-11.