Nursing Care Plan Template
A free nursing care plan template using the ADPIE framework. Covers assessment, nursing diagnosis, planning, interventions, and evaluation. No signup or email required.
What are nursing notes?
Nursing notes are written records documenting a patient's status, care provided, and response during a shift or clinical encounter. They are a legal record and follow the SOAPIE format - Subjective, Objective, Assessment, Plan, Intervention, Evaluation.
The template
Nursing Notes Template
NURSING NOTES - SOAPIE FORMAT
Patient identifier:
[Hospital number]
Date:
[Date]
Time:
[Time]
Nurse:
[Name and role]
Ward:
[Ward name]
Note type:
- Routine shift note
- Clinical change note
- Post-procedure note
- Response to deterioration
- End of shift note
- Other:
S - SUBJECTIVE | What did the patient report?
[Document what the patient said in their own words where possible. Include reported symptoms, pain, concerns, and any changes the patient has noticed since the last assessment.]
Pain:
Location:
Character:
Score:/ 10
Onset:
What makes it better or worse:
Other symptoms reported:
[Document any other symptoms the patient reports - nausea, breathlessness, dizziness, fatigue, mood, etc.]
O - OBJECTIVE | What did you observe and measure?
Vital signs:
Temperature:°C
Blood pressure:/
Heart rate:bpm
Respiratory rate:breaths/min
Oxygen saturation:%
Blood glucose:
Weight (if relevant):
Physical observations:
General appearance:
[Alert / Distressed / Comfortable / Pale / Flushed / Diaphoretic]
Neurological:
[GCS score / Confusion / Orientation]
Respiratory:
[Effort / Air entry / Adventitious sounds]
Cardiovascular:
[Pulse character / Oedema / Perfusion]
Abdomen:
[Distension / Tenderness / Bowel sounds]
Skin and wounds:
[Integrity / Colour / Wound appearance if applicable]
Mobility:
[Ambulant / Assisted / Non-mobile]
Fluid balance (if documented):
Input:mL
Output:mL
Balance:mL
Relevant investigation results:
[Document any new lab results, imaging findings, or test results since last note]
A - ASSESSMENT | What is your clinical judgment?
Current status:
- Stable - no change from previous note
- Improved - describe:
- Deteriorating - describe:
- Condition changed - describe:
Active clinical problems this encounter:
Problem 1:
Problem 2:
Problem 3:
Nursing concerns:
[Document your clinical concern - what you are worried about and why. This is your professional judgment based on the subjective and objective findings above.]
Was a doctor or senior clinician notified?
- Yes - Name:Time:Reason:Response:
- No
P - PLAN | What is planned for this patient?
Monitoring plan:
[What will be monitored, how often, and by whom]
Medication plan:
[Any medication changes or PRN medications administered - reference medication chart]
Procedure or treatment plan:
[Any planned procedures, dressings, or treatments]
Referrals:
[Any referrals made or pending]
Patient or carer education:
[What was discussed with the patient or carer]
I - INTERVENTION | What did you do?
[Document all nursing actions taken during this encounter - be specific and include times where relevant]
- Vital signs taken - time:
- Medication administered - see medication chart
- Wound dressing performed - describe:
- Patient repositioned - time:
- IV cannula inserted/resited - site:
- Catheter care performed
- Nasogastric tube checked - position confirmed: ☐ Yes
- Patient assisted with personal care
- Patient education provided - topic:
- Doctor notified - name and time:
- Family or carer updated
- Escalation initiated - protocol:
- Other:
E - EVALUATION | How did the patient respond?
Response to interventions:
[Document how the patient responded to the care provided - did the intervention achieve the intended effect?]
Pain reassessment (if applicable):
Score after intervention:/ 10
Time of reassessment:
Clinical status at end of encounter:
- Improved
- Unchanged
- Deteriorated - action taken:
Outstanding issues to handover:
[Document anything the incoming nurse must know about this patient at the next handover]
SIGN-OFF
Nurse:
Name:Role:Signature:Time:
DOCUMENTATION RULES
- All entries are factual and objective
- No blank spaces left unfilled - write N/A where not applicable
- No use of correction fluid - draw a single line through errors and initial
- No abbreviations unless on the approved list for your organisation
- Entry signed with name, role, and time
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What this template covers
Patient header
identifier, date, time, nurse, ward, and note type
S - Subjective
patient-reported symptoms, pain location, character, score, and other reported concerns
O - Objective
vital signs, physical observations across all body systems, fluid balance, investigation results
A - Assessment
current status, active clinical problems, nursing concerns, clinician notification record
P - Plan
monitoring, medication, procedures, referrals, patient education
I - Intervention
specific nursing actions taken with times, using a checklist format
E - Evaluation
patient response to interventions, pain reassessment, clinical status at end of encounter, handover items
Sign-off
name, role, signature, time
Documentation rules
factual, no blanks, no correction fluid, approved abbreviations only
How to use this template
Complete the header immediately
Fill in patient identifier, date, time, and note type before writing anything else.
Write S and O before your assessment
Document what the patient told you and what you observed before forming your clinical judgment - this keeps your assessment grounded in evidence.
Write A - your clinical judgment
State clearly what you think is happening and what you are concerned about. If you notified a doctor, document the name, time, reason, and response.
Complete I - be specific about actions
Tick every intervention completed and add times where relevant. Vague entries like "care given" are not acceptable - document exactly what was done.
Complete E - document the patient response
Every intervention must have a documented patient response. If you administered pain medication, record the pain score before and after.
Sign off and note handover items
Complete the sign-off with your name, role, and time. List anything the incoming nurse must know in the outstanding handover section.
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