Clinical skills · Documentation

Same patient, same morning, three ways to chart it.

SOAP isn't the only format you'll meet in clinicals. Many facilities use focused DAR notes, narrative notes, or charting by exception. Here's how each one works, written up for the same patient so you can see the differences.

NCL

NurseCaseLab Editorial Team
Published October 8, 2026 · 8 min read

Illustrative photograph · documentation

Students often learn one documentation format in class and then find a different one on their clinical unit. The good news: every format records the same clinical reasoning. What you noticed, what you did, and how the patient responded. Once you can see that structure, switching formats is just rearranging it.

01 / Overview

The formats at a glance.

Open RN's Nursing Fundamentals lists several common documentation formats, including charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, and discharge summaries. Whatever the format, every entry must include the date, time, and your signature, and must be objective, factual, and professional.

SOAP / SOAPIE: Organized around clinical reasoning: subjective, objective, assessment, plan (plus intervention and evaluation). See our SOAP note guide.
Focused DAR: A brief note about one patient problem: Data, Action, Response.
Narrative: A chronological account of assessments and nursing care across the shift or visit.
By exception: Normal findings are confirmed against a standard list; notes are written only for abnormal findings and significant events.

02 / Focused DAR

Focused DAR notes: one problem per note.

DAR stands for Data, Action, Response. Each note starts with a focus, which is the patient problem, concern, or event the note is about. The focus may be a nursing diagnosis, a symptom, a change in condition, or an event such as a fall or a transfer. Because each note covers one problem, DAR notes are quick to write and quick to read. They're often used alongside charting by exception.

D / Data

What you found

Assessment information related to the focus: vital signs, exam findings, and what the patient said.

A / Action

What you did

The nursing actions planned and carried out for this problem, including notifications.

R / Response

What happened

How the patient responded, and whether the care was effective.

03 / Worked example

A DAR note for Mr. D.

Mr. D. is the fictional 72-year-old with pneumonia from our clinical skills series. Here is his morning, focused on breathing, as a single DAR entry:

Focus: Ineffective airway clearance
D (0800): Respirations 24, SpO₂ 90% on 2 L/min nasal cannula (93% at 0400). Crackles right lower lobe, diminished at right base. Productive cough, moderate yellow sputum. Patient states, "It hurts on my right side when I cough." Pain 4/10.
A (0800–1000): Head of bed elevated to 45 degrees. Coached coughing and deep breathing with pillow splinting; incentive spirometer, 10 breaths hourly while awake. Oral fluids encouraged. Provider notified at 0820 using SBAR; new orders received, read back, and implemented.
R (1100): Respirations 20, SpO₂ 93% on 2 L/min. States, "It's easier to cough stuff up now." Pain 3/10. Crackles persist right lower lobe. Improving; continue plan and reassess per protocol.

Notice that the R is not "tolerated well." It gives the same measurements as the D, so anyone reading can see the change for themselves. The 1100 data come from the focused respiratory reassessment.

04 / Narrative

Narrative notes: the shift as a story.

A narrative note records assessment findings and nursing care in time order across the shift or visit. It's flexible, which makes it useful for complex events, such as a deterioration, a fall, or a difficult conversation, where the sequence matters. That flexibility is also its weakness: without structure, narrative notes get long, repetitive, and hard to scan. Here's the same morning as a narrative entry:

Narrative example

0800: Patient alert and oriented ×4, sitting upright in bed. Respirations 24, SpO₂ 90% on 2 L/min via nasal cannula, down from 93% at 0400. Crackles auscultated right lower lobe with diminished sounds at right base. Productive cough with moderate yellow sputum. Reports right-sided pain with coughing, 4/10. Head of bed raised to 45 degrees; coughing, deep breathing, and incentive spirometer use coached. 0820: Provider notified by phone of decreased SpO₂ and low urine output; orders received and read back. 1100: Respirations 20, SpO₂ 93% on 2 L/min. Patient states coughing is easier. Pain 3/10. Crackles persist right lower lobe. Will continue to monitor.

Good narrative notes still follow a pattern: time, finding, action, response, repeated. Write each entry as soon as practical after the care happens, not in a block at the end of the shift.

05 / By exception

Charting by exception: only what's different.

Charting by exception (CBE) was designed to save time. The facility defines a standard list of normal findings for each system. After assessing, you confirm the findings that match the standard, often with a click or checkbox in the electronic health record, and write brief notes only for abnormal findings or to document communication with the team.

For Mr. D., a nurse using CBE would confirm the normal neurological, cardiovascular, and skin findings against the standard, document the abnormal respiratory and fluid findings as exceptions, and add a DAR note for the airway problem and the provider call.

The CBE trap

Confirming "within normal limits" means you assessed it and it matched the standard. Never confirm a normal finding you didn't actually assess. In a legal review, the chart is treated as a record of what you did.

06 / Choosing

Which one should you use?

The one your facility and program require. Documentation format is set by policy, and on graded work your instructor's format wins. What carries across every format is the content: specific findings, the actions you took, the patient's response, who you told, and when.

I'm using my facility's or program's required format. Each entry has a date, time, and signature. My DAR note has one clear focus. My response section uses the same measurements as my data section. I only confirmed normal findings I actually assessed.

Keep going

Compare formats, then avoid the classic mistakes.

Documentation

The same morning written as a SOAP note.

Documentation

Nursing charting mistakes and how to fix them.

Practice in simulation

Documenting a discharge in Shadow Health?

The Tina Jones discharge assessment brings documentation together with medication reconciliation, patient education, and follow-up planning. NursingProxy has a study guide for that module.

See the Tina Jones discharge study guide Relationship disclosure: NurseCaseLab and NursingProxy are related learning properties. This external resource is optional and isn't required to use this guide. Follow your program's academic integrity policy.

Sources & further reading

Read the formats in the source.

Mr. D. is a fictional teaching case. This guide is nursing education, not legal advice. Follow your facility's documentation policy. Shadow Health is an Elsevier product; NurseCaseLab isn't affiliated with or endorsed by Elsevier.