Writing nursing notes is a big part of every psychiatric nurse’s day. Some nurses enjoy the documentation process. Others find it tedious and put it off until the end of their shift. But no matter how you feel about it, we all have to do it. The truth is, good notes make your job easier. They help you remember what happened with each patient. They communicate important information to the next shift. They give doctors and therapists the details they need to make treatment decisions. And yes, they protect you and your patients if any questions come up later.

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Psychiatric nursing notes are different from notes in other parts of the hospital. In medical-surgical units, nurses write about wounds and vital signs and post-op recovery. In psych nursing, we write about feelings and behaviours and thoughts. We document what patients say, how they act, whether their mood is improving or getting worse. Our notes tell the story of each patient’s mental health journey. When done well, they give a clear picture that helps the entire treatment team provide better care.

In this blog post, I will walk you through different types of nursing notes. I will explain each format and give you complete examples you can learn from and adapt for your own practice. Whether you are a new grad just learning or an experienced nurse who wants to refresh your skills, there will be something useful here for you.

Why Are Psychiatric Nursing Notes So Important?

Psychiatric nursing notes are different from other nursing notes. In other parts of the hospital, nurses write about wounds and medicines and vital signs. In psych nursing, we write about feelings and behaviors and thoughts.

Our notes tell the story of our patient’s mental health. They show if a patient is getting better or worse. They help the treatment team make good choices about care.

Good notes also protect nurses. If there is ever a question about what happened on your shift, your note is your proof. It shows what you saw and what you did.

Bad notes can cause problems. If your note is not clear, someone might not understand what happened. If your note is missing information, you might forget important things. If your note has wrong information, it could hurt the patient.

So let us learn how to write great notes!

The Basics of Good Psychiatric Nursing Notes

Before we look at different note formats, let us talk about what all good notes have in common.

Be Objective: Write what you see, not what you think. Instead of writing “The patient was angry,” write “The patient raised his voice and clenched his fists.” See the difference? The first one is your opinion. The second one is what you actually saw.

Be Accurate: Check your facts. Make sure you have the right patient name. Make sure your times are correct. Make sure you spell medicines right.

Be Complete: Include all important information. What did you see? What did you do? What did the patient say? What happened next?

Be Timely: Write your note as soon as you can. If you wait too long, you might forget things. Most hospitals want notes done before your shift ends.

Be Professional: Use proper words. Do not use slang. Do not use words that sound mean or judgmental. Write like the professional nurse you are.

The SOAPIE Format

SOAPIE is one of the most common ways to write nursing notes. Many hospitals use this format. It is easy to remember and it makes sure you include everything.

S stands for Subjective
O stands for Objective
A stands for Assessment
P stands for Plan
I stands for Intervention
E stands for Evaluation

Let me explain each part.

Subjective

This is what the patient tells you. You write it exactly like the patient said it. Use quotation marks. For example: Patient stated, “I am feeling much better today. The voices are not as loud.”

Objective

This is what you observe. These are facts you can see, hear, touch, or smell. For example: Patient was sitting in the day room. Patient was wearing clean clothes. Patient made eye contact during conversation.

Assessment

This is your nursing judgment. Based on what the patient said and what you saw, what do you think? For example: Patient appears to be responding well to medication. Mood seems improved from yesterday.

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Plan

This is what you plan to do next. For example: Will continue to monitor mood. Will encourage group participation.

Intervention

This is what you actually did. For example: Spent 10 minutes talking with patient about coping skills. Reminded patient to take evening medication.

Evaluation

This is how the patient responded to your interventions. For example: Patient was able to name three coping skills. Patient took medication without complaint.

SOAPIE Note Example

Here is a complete SOAPIE note for a patient named Maria.

S (Subjective): Patient stated, “I slept pretty good last night. I only woke up once.” Patient also said, “I am ready to go to group today. The last group helped me.”

O (Objective): Patient was awake and dressed when I entered her room at 0800. Patient had brushed her hair and put on clean clothes. Patient smiled when I said good morning. Patient ate all of her breakfast. Vital signs: BP 118/76, HR 72, RR 16, Temp 98.6.

A (Assessment): Patient’s mood appears improved from yesterday. Yesterday patient was tearful and stayed in bed. Today patient is engaging and positive. Patient reports good sleep and appetite.

P (Plan): Continue current medications. Encourage patient to attend morning group. Offer one-to-one time after lunch to discuss discharge plans.

I (Intervention): Accompanied patient to morning group at 0900. Patient participated in group discussion about anxiety management. At 1100, met with patient for 15 minutes to discuss discharge planning.

E (Evaluation): Patient stayed for entire group session and shared one coping skill with the group. During one-to-one time, patient identified a safe place to live after discharge and has a follow-up appointment scheduled. Patient states she feels ready for discharge.

The DAR Format

DAR is another popular format for psychiatric nursing notes. It is shorter than SOAPIE. Some nurses like it because it is quick. Some hospitals use it for shift notes.

D stands for Data
A stands for Action
R stands for Response

Data

This is the information you collect. It includes both subjective and objective information. What did the patient say? What did you see?

Action

This is what you did. What interventions did you perform? What did you do to help the patient?

Response

This is how the patient responded to your actions. Did the patient get better? Did the patient calm down? Did the patient follow your suggestions?

DAR Note Example

Here is a DAR note for a patient named James.

D (Data): At 1430, patient was found pacing in the hallway. Patient was talking loudly to himself. Patient stated, “I cannot sit still. Something bad is going to happen.” Staff observed patient rubbing his hands together and looking around nervously.

A (Action): Approached patient calmly. Spoke in a quiet voice. Offered patient a PRN medication for anxiety. Guided patient to a quiet area away from other patients. Stayed with patient and used calming techniques.

R (Response): Patient agreed to take PRN medication. After 30 minutes, patient stopped pacing. Patient sat down in a chair and was able to take deep breaths. Patient stated, “I feel a little better now. Thank you for staying with me.”

The Focus Note Format

Focus notes are also called charting by exception. You write about specific problems or concerns. You do not write about everything. You just write about the things that are important or different.

Each focus note has three parts: Focus, Data, and Progress.

Focus

This is the topic of your note. It could be a symptom, a behavior, or a patient goal. For example: “Auditory hallucinations” or “Refusal to eat” or “Anxiety level.”

Data

This is the information about the focus. What is happening with this specific problem?

Progress

This is what you did and how the patient responded. Is the patient getting better or worse with this focus area?

Focus Note Example

Here is a focus note for a patient named David.

Focus: Sleep Pattern Disturbance

Data: Patient reported at 0700 that he only slept about 3 hours last night. Patient stated, “I kept waking up and could not fall back asleep.” Night shift report indicates patient was up walking in the hallway at 0200 and again at 0430. Patient appears tired this morning. Yawning frequently.

Progress: Discussed sleep hygiene with patient. Reviewed ways to improve sleep such as avoiding caffeine at night and using relaxation exercises. Patient agreed to try listening to calming music before bed tonight. Will monitor sleep pattern and offer sleep medication if ordered and if needed.

The Intake Note Format

When a patient first comes to the psychiatric unit, you need to write an intake note. This is also called an admission note. It is very important because it gives a baseline. It shows how the patient was when they first arrived.

An intake note usually includes:

• How the patient got to the unit
• How the patient looks and acts
• What the patient says about why they are here
• Safety concerns
• Immediate needs

Intake Note Example

Here is an intake note for a new patient named Robert.

Date/Time of Admission: 11/15/2023 at 1930 hours

Admitted from: Emergency Department via wheelchair with ED nurse

Mode of arrival: Alert and oriented x 3, walked to room with assistance

General Appearance: Patient is a 45-year-old male wearing hospital gown and socks. Patient has not shaved in several days. There is a strong smell of body odor. Patient avoids eye contact.

Behavior: Patient is sitting on edge of bed. Patient is quiet and does not speak unless spoken to. Patient moves slowly.

Speech: Soft, slow, brief answers. Takes long pauses before responding.

Mood/Affect: Patient states his mood is “sad.” Affect is flat. No smiling or frowning.

Thought Content: Patient states, “I just want to be left alone.” Denies thoughts of hurting self or others at this time. Denies hallucinations.

Safety: Patient belongings searched according to policy. No contraband found. Patient placed on 15-minute checks per doctor order.

Vital Signs: BP 132/84, HR 88, RR 18, Temp 98.4, O2 sat 98%

Nursing Interventions: Oriented patient to unit. Showed patient his room and bathroom. Explained unit rules and schedule. Offered food and fluid. Patient accepted juice and crackers. Informed patient that doctor will see him in the morning.

Plan: Will monitor for withdrawal symptoms. Will encourage hygiene. Will continue suicide precautions. Will introduce to other patients and staff as tolerated.

Signature: Sarah Johnson, RN

The Group Note Format

In psychiatric nursing, we often run therapy groups. We need to write notes about these groups. Group notes are different from individual notes. They talk about the group as a whole and also about each patient’s participation.

Group notes usually include:

• Type of group
• Topic of group
• How long the group lasted
• Who led the group
• Which patients attended
• How each patient participated
• How the group went overall

Group Note Example

Here is a group note for a coping skills group.

Group: Coping Skills Group
Date: 11/16/2023
Time: 1000-1045
Leader: Sarah Johnson, RN
Topic: Deep Breathing Techniques

Group Description: Group met in the day room. Seven patients attended. Nurse demonstrated three different deep breathing exercises. Patients practiced each technique. Discussion followed about when to use deep breathing.

Individual Patient Participation:

• Maria: Participated fully. Practiced all exercises. Shared that she uses deep breathing when she feels anxious.
• James: Sat quietly at first. After encouragement, tried the exercises. Stated he felt “a little silly” but would try again.
• David: Very engaged. Asked questions. Helped encourage other patients.
• Susan: Participated minimally. Sat with arms crossed. Did not want to practice. Remained in group but did not engage.
• Robert: Participated appropriately. Stated the exercises helped him feel calmer.
• Linda: Arrived late at 1015. Caught up quickly. Practiced with the group.
• Thomas: Good participation. Shared that he learned deep breathing in the military.

Group Response: Group was cooperative. Some laughter during practice but in a positive way. Patients supported each other. At the end, patients reported feeling more relaxed.

Plan: Will offer another coping skills group next week. Will check in with Susan individually about her lack of participation.

The Shift Summary Note

At the end of your shift, you need to write a summary note. This tells the next shift what happened and what still needs to be done. It helps with continuity of care.

A shift summary note usually includes:

• Brief overview of the patient’s day
• Any significant events
• How the patient is at the end of your shift
• What still needs to be done
• Information for the next shift

Shift Summary Note Example

Here is a shift summary note for evening shift.

Shift: 1500-2330
Date: 11/16/2023
Patient: Maria

Summary of Shift: Patient had a good day overall. Attended coping skills group at 1000. Ate all meals. Visited with family from 1800-1900. After family left, patient was tearful for about 15 minutes. Stated she misses her children. Staff sat with patient and offered support. Patient calmed down and went to the day room to watch TV.

Medications: All evening medications given at 2100. Patient took them without issue.

Vital Signs: Taken at 2200. BP 120/70, HR 76, Temp 98.6. Within normal limits.

Sleep: Patient went to her room at 2230. Lights out at 2300. Patient stated she is tired and ready to sleep.

Safety: No safety concerns this shift. Patient denies thoughts of self-harm.

Unfinished Tasks: Patient needs lab work in the morning before breakfast. Order is in the computer.

Information for Next Shift: Patient’s mother called and will visit again tomorrow afternoon around 1400. Patient may need extra support before and after visit.

Signature: Sarah Johnson, RN

The Incident Note Format

Sometimes things happen on the unit that are not normal. A patient might fall. A patient might become aggressive. A patient might need restraints. These are called incidents. They need special notes.

Incident notes must be very detailed and very accurate. They must tell exactly what happened from beginning to end. They are used for hospital reports and sometimes for legal reasons.

An incident note should include:

• Exactly what happened
• When it happened
• Where it happened
• Who was involved
• What led up to it
• What staff did
• How the patient responded
• What happened after
• Who was notified

Incident Note Example

Here is an incident note about a patient who became aggressive.

Date: 11/17/2023
Time of Incident: 1430
Location: Day room
Patient: James

Description of Incident:

At approximately 1425, patient James was sitting in the day room watching television. Another patient, Robert, sat down in the chair next to James. According to witnesses, James immediately stood up and began yelling at Robert.

James shouted, “Get away from me! Do not sit by me!” Robert did not respond and remained seated. James then picked up a magazine from the table and threw it toward Robert. The magazine did not hit Robert. It landed on the floor.

I was at the nursing station and heard the yelling. I went immediately to the day room. When I arrived, I saw James standing with his fists clenched. His face was red. He was breathing heavily.

Staff Response:

I used a calm voice and said, “James, let us go to the quiet room and talk.” James did not respond at first. I repeated the statement. James then said, “He was too close to me. He needs to move.”

I maintained a safe distance and kept my body turned slightly to the side. I continued to speak calmly. I asked another staff member to redirect Robert to another area of the unit.

When Robert left the day room, James began to calm down. His shoulders relaxed. His breathing slowed. He agreed to go to the quiet room with me.

Patient Response:

In the quiet room, James sat down in a chair. He was able to talk about what happened. He stated, “I do not like people in my space. It makes me crazy.” I reviewed coping skills with him. He was able to take deep breaths. After about 20 minutes, James stated he felt calm enough to return to the day room.

Follow-up:

James returned to the day room at 1455. He sat in a chair away from other patients. He watched television quietly. No further incidents this shift.

Notified:

Dr. Smith was notified at 1445. Dr. Smith ordered to continue current plan and monitor closely. Charge nurse was present during incident. Incident report completed per hospital policy.

Signature: Sarah Johnson, RN

Tips for Writing Better Psychiatric Nursing Notes

Now that you have seen different formats, let me share some tips that will help you write better notes.

Use the Patient’s Own Words: When you write what the patient said, use quotation marks. This shows it is exactly what the patient said, not your summary. For example: Patient stated, “The voices are telling me to hurt myself.” This is much stronger than writing “Patient reported command hallucinations.”

Describe Behaviors, Not Labels: Instead of writing “patient was manipulative,” describe what the patient did. For example: “Patient asked three different staff members for extra snacks within one hour.” See how that shows the behavior without judging the patient?

Be Specific About Times: Do not write “earlier today” or “this morning.” Write actual times. For example: “At 0900, patient went to group. At 0915, patient left group.” This helps everyone know exactly when things happened.

Include Negative Findings: Sometimes what did not happen is just as important as what did happen. For example: “Patient denied suicidal thoughts. No signs of hallucinations observed.” This shows you checked for these things even if they were not present.

Write So Others Can Understand: Remember that your notes might be read by many people. Doctors read them. Other nurses read them. Social workers read them. Sometimes lawyers read them. Write so anyone can understand.

Keep Learning: The best nurses never stop learning. Read other nurses’ notes. Ask for feedback on your notes. Go to training when your hospital offers it. Every note you write is a chance to get better.

Common Mistakes to Avoid

Let me tell you about some common mistakes nurses make. If you avoid these, your notes will be much better.

Vague Language

Mistake: “Patient had a good day.”

Better: “Patient attended all groups, ate all meals, and interacted positively with peers.”

Opinions Without Facts

Mistake: “Patient was very anxious.”

Better: “Patient was pacing, rubbing hands together, and stated ‘I feel really nervous right now.'”

Forgetting to Sign

Always sign your notes with your name and title. An unsigned note is not complete. It might not count.

Writing Too Little

Do not write just one sentence. Give enough information so someone reading later knows what happened.

Writing Too Much

Do not write everything the patient said for eight hours. Focus on what is important for their care.

Using Abbreviations No One Knows

Every hospital has approved abbreviations. Use only those. If you are not sure, write the whole word.

Waiting Too Long to Write

Write notes as soon as you can. Memory is not perfect. The longer you wait, the more you might forget.

Special Considerations in Psychiatric Nursing Notes

Psychiatric nursing has some special things you need to think about when writing notes.

Confidentiality: Psychiatric notes are very private. Be careful where you write them. Be careful who you show them to. Follow all HIPAA rules. Do not leave notes where others can see them.

Legal Issues: Psychiatric patients sometimes go to court. Your notes might be used as evidence. Write them like you might have to read them in court someday. Because you might!

Stigma: Mental illness still has stigma. Some people judge patients based on their diagnosis. Write in a way that respects your patient. Do not use words that make them sound bad or crazy.

Safety Concerns: If a patient is a danger to themselves or others, your notes must be very clear. Document all safety checks. Document all conversations about safety. Document every time you assess for risk.

Conclusion

Writing good psychiatric nursing notes takes practice. It is a skill you build over time. The more notes you write, the easier it becomes. You will find a rhythm that works for you. You will learn what information matters most and how to write it clearly.

Remember that your notes are not just paperwork. They are a record of the care you provided. They tell the story of your patient’s progress. They help the next nurse know what to do. They give doctors and therapists the information they need. And when questions come up later, your notes are there to show what happened.

Start with the basics.

• Be objective.
• Be accurate.
• Be complete.
• Be timely
• Be professional

Use the format your hospital prefers. Include what the patient said and what you observed. Document what you did and how the patient responded. Keep it professional and clear.

Every note you write is a chance to get better. Do not be too hard on yourself if they are not perfect at first. None of us started out writing great notes. We learned by doing, by making mistakes, and by getting feedback. You will too.

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