User Guide
How Nurse Charting Pro works end-to-end — from picking your specialty and adding rooms, to generating an AI narrative or an SBAR, to sending a chart to Epic or Cerner, to ending the shift and crypto-shredding the data.
The most important thing to know up front: the app never asks for a patient name, medical record number, or date of birth, and never stores one. Charts are tied to room numbers only. That is what makes end-of-shift crypto-shredding meaningful — there is nothing on the device that can be tied back to a specific patient.
The room-based model (read this first)
Nurse Charting Pro never asks for a patient name, medical record number, or date of birth — and never stores them. The only identifier you enter is a room number (and optionally a bed). That is the entire HIPAA-by-design story: nothing on your device, on our servers, or in any export can be tied back to a specific patient by us, by a vendor, or by a subpoena.
What you enter
- A room number (required). A bed letter or number (optional).
- Optional shift metadata — start time, your initials if you want them on the narrative, the closing line you prefer.
- No name, no MRN, no DOB, no insurance, no demographics. Ever.
Why it works this way
You already know who is in Room 412 — your assignment sheet, the wristband, and your clinical handoff cover that. The app does not need to know. By keeping the patient identifier off-device, the encrypted chart cannot be re-identified after the shift ends, even if the device is later compromised.
A note on rooms vs. charts
A single room can have more than one chart in a single shift (a turnover, a transfer, a re-assessment). The app handles that automatically — picking a room from your assignment list opens the right chart, and ending the shift wipes all of them together.
Getting started
Download from the App Store or Google Play, open the app, and skip account creation — there is none. You will pick your specialty, optionally set your care setting, and start charting.
First launch
- Install Nurse Charting Pro from the App Store or Google Play.
- Open the app — there is no sign-up, no email, no password.
- Pick a specialty for this shift: Psych Chart or Clinical Chart. You can chart both kinds of patients in the same shift; the picker appears each time you start a new chart.
- Add the rooms you are responsible for from the Room Assignment screen, then tap a room to start charting.
For clinical charts: care setting and care programs
The first time you open a Safety Check on a clinical chart, the app asks you to set the care setting (e.g., med-surg, home health, long-term care, skilled nursing) and any active care programs (e.g., CHRONIC CARE, REHAB, HOSPICE). These tags shape the assessments you see and the language the AI uses in the narrative. You can change them per chart.
iPhone, iPad, and Android
The app runs on iOS 13+ (iPhone and iPad) and Android 8+. Layouts adapt to tablet — there are no phone-only gestures or hidden swipes you have to learn.
Charting — psychiatric (8 categories)
A psych chart breaks down into eight categories. Each one is a structured set of taps and selections; the language is standardized so the AI narrative comes out clean. You can chart them in any order and a progress bar shows what is left.
- Environment & Status — Room conditions, awake/asleep status, and visible safety hazards before you sit down with the patient.
- Mental & Emotional — Mental status exam, mood, affect, orientation, and engagement.
- Thought & Behavior — Thought process and content, perceptual disturbances, observed behavior on the unit.
- Safety Assessment — Suicidal/homicidal ideation, plan/intent, agitation, elopement risk, and the supports already in place.
- Speech & Interactions — Rate, rhythm, content, and how the patient is interacting with peers and staff.
- Function & Daily Living — ADLs, hygiene, sleep, appetite, and group/program participation.
- Medical & Monitoring — Vital signs, PRN use, side effects, and medical concerns to flag.
- Summary & Monitoring — Free-text wrap-up that feeds the AI narrative and SBAR.
When the patient is asleep, the unrelated categories collapse into a sleep-check workflow so you do not chart what you cannot observe.
Charting — clinical (8 categories)
A clinical chart covers the full bedside picture for med-surg, home health, long-term care, and similar settings. Like psych, it is eight structured categories you can chart in any order.
- Safety Check — Care setting, care programs, fall and skin precautions, alarms, restraints, and safety equipment in place.
- Vitals — Temperature, pulse, respirations, blood pressure, oxygen, and pain.
- Morse Fall Scale — Standardized fall-risk scoring with the live total surfaced as you tap.
- Glasgow Coma Scale — Eye, verbal, and motor scoring for neuro checks, with the GCS total calculated for you.
- Skin/Wound — Skin integrity, pressure-injury staging, and wound assessment.
- IV Lines — Site, gauge, dressing, patency, and infusion notes per line.
- Head to Toe Assessments — System-by-system assessment — neuro, cardiovascular, respiratory, GI, GU, musculoskeletal, integumentary.
- Notes & Education — Free-text nursing notes plus patient/family education delivered.
Morse Fall Scale and Glasgow Coma Scale tally the score for you in real time as you tap; you do not have to add anything up by hand.
AI narrative generation
When you finish a chart, tap Review & Generate. The AI takes your structured selections and produces a professional, CPRS-formatted nursing note that you can edit before exporting.
How it works
- Complete the categories you want to include.
- Tap Review & Generate — the app shows you exactly what is being sent (your selections, never patient identifiers).
- The narrative comes back in seconds and lands in an editable text box on your device.
- Edit it freely, then copy it or share it through the share sheet.
Free pool: 8 generations per install
Every install gets eight free narrative generations to try the app on real shifts. The counter lives in the iOS Keychain or Android Keystore, so reinstalling the app does not reset it. The same eight-generation pool is shared with SBAR — generating a narrative or an SBAR each consumes one.
After the free pool: subscription
Pro and Pro Plus subscribers generate unlimited narratives. Trial users (any tier) also get unlimited narratives during the 30-day trial. See Subscription management below.
Output format
Narratives come out as plain text formatted for CPRS-style nursing notes. There is no PDF export — the deliberate choice is plain text that you can paste into any EHR field, AirDrop to yourself, or share through the system share sheet to email, Files, Drive, or anything else you have installed.
SBAR verbal handoff reports (Pro Plus)
SBAR is a separate, structured verbal handoff report — Situation, Background, Assessment, Recommendation — meant to be read aloud at shift change. It is generated from the same chart data as the narrative but formatted for spoken handoff rather than written documentation.
Both psych and clinical SBAR
SBAR exists in both specialties, with templates tuned for each. A psych SBAR emphasizes safety, mental status changes, and behavioral plans; a clinical SBAR emphasizes vitals trends, lines, wounds, and pending orders.
How to generate one
- On the categories screen for a chart, tap Verbal Handoff Report.
- Edit the generated SBAR if you want to add or trim anything — it is fully editable.
- Copy it or share it for the oncoming nurse.
Subscription tier — Pro Plus only
SBAR is included with Pro Plus and with active trials. Pro alone does not include SBAR — a Pro paid subscriber tapping SBAR will see an upgrade-to-Pro-Plus paywall, not the free pool. Non-subscribers can use SBAR from the same shared 8-generation free pool that AI narratives draw from.
Send to EHR (Epic and Cerner)
Send to EHR posts the generated narrative directly to the patient chart in Epic or Oracle Health (Cerner) using SMART on FHIR. You authenticate with your own EHR credentials in the system browser; the app never sees your username or password.
Availability
Send to EHR is currently in sandbox testing against Epic and Cerner; production hospital integration is on the roadmap.
First-use consent
The first time you tap Send to Epic or Send to Cerner, the app shows a consent modal that explains exactly what will be transmitted: a clinical narrative, filed as a FHIR DocumentReference to the patient chart you select. The modal also reminds you to verify the patient identity before confirming and to make sure transmission is allowed under your facility policy. You acknowledge once and the modal does not appear again — the acknowledgment is remembered across shifts. You can reset it any time from Settings → EHR.
How the auth flow works
Authentication runs in the system browser using OAuth 2.0 with PKCE. Your EHR credentials are entered into the EHR's own login page — Nurse Charting Pro never sees them. Once you are signed in, the app receives a short-lived access token that lets it post the narrative on your behalf.
What is transmitted
Only the finished narrative goes to the EHR, packaged as a FHIR DocumentReference. The structured chart selections behind the narrative stay on your device.
Technical detail
The full OAuth/PKCE/scopes write-up — including the launch context handling and DocumentReference shape — lives in the FHIR review notes (linked below) so this guide can stay focused on the nursing workflow.
C-CDA export
C-CDA export turns the chart into a standards-compliant clinical document XML file on your device, then hands it to the system share sheet so you decide where it goes.
On-device, no transmission
The C-CDA file is generated locally — no server, no authentication, no transmission to us. The share sheet then lets you send it to email, AirDrop, Files, Drive, or any other destination you have set up.
When to use it
C-CDA is the right choice when the receiver wants a structured exchange document rather than a free-text narrative — for example, transitions of care, an outside provider request, or a personal health record import.
Subscription management
Two paid tiers, a 30-day free trial, and an in-app management screen. Subscriptions are billed by Apple or Google through your store account.
Plans
- Pro — $4.99/month. Unlimited AI narrative generation. Send to EHR. C-CDA export. CPRS-formatted text export.
- Pro Plus — $6.99/month. Everything in Pro, plus unlimited SBAR verbal handoff reports.
- Free — no subscription. 8 generations total per install (shared between narratives and SBAR). All other features available.
30-day free trial
Both Pro and Pro Plus offer a 30-day free trial. The trial is billed through the App Store or Google Play, so a payment method is required to start it. Cancel before the trial ends and you will not be charged. During the trial you have unlimited narratives and unlimited SBAR regardless of which tier you started.
Manage your subscription in-app
Open Settings → Manage Subscription. That opens the in-app Customer Center where you can switch plans, cancel, or restore purchases — you do not have to dig into Apple ID Subscriptions or Google Play Subscriptions for routine changes. If the in-app Customer Center is unavailable for any reason, the app falls back to the platform's native subscription settings.
Restore Purchases
If you reinstall the app or move to a new phone, tap Restore Purchases on the Subscription screen or paywall to bring your subscription back. Your charts do not transfer — they were already crypto-shredded at end of shift — but your subscription does.
End of shift — crypto-shredding
When you end your shift, the app destroys the encryption key that protected that shift's data. The encrypted blobs on the device become mathematically unrecoverable — there is no undo, no cloud backup, and no recovery flow. Export anything you need to keep before you tap End Shift.
What gets deleted
- Every chart from this shift — psych and clinical, completed and partial.
- Every generated narrative and every SBAR for this shift.
- Every wound photo, IV note, and free-text entry tied to this shift.
What is kept
- Your subscription status (Pro, Pro Plus, trial — handled by the store, not by us).
- Your settings — preferred specialty, weight unit, custom closing, EHR consent acknowledgment.
- Your free-narrative counter (lives in the Keychain/Keystore — install-scoped, not shift-scoped).
Export reminders before you end shift
- Copy or share any narratives you need for paper/EHR documentation.
- Send to EHR for any charts that need to land in Epic or Cerner.
- Export C-CDA for transitions-of-care or anything you need to send to an outside provider.
Resume shift mid-chart
If you have to put the app down and come back later in the same shift, just reopen it — the chart you were working on is exactly where you left it. Crypto-shredding only happens when you explicitly tap End Shift.
Still have questions?
The FAQ covers most common questions about subscriptions, privacy, and supported features. If something is missing, our support team typically responds within 24 hours.